Provider Demographics
NPI:1013774397
Name:GEORGE, STACEY ANNE (RMHCI)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANNE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 A1A N STE 203
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4098
Mailing Address - Country:US
Mailing Address - Phone:904-569-6875
Mailing Address - Fax:
Practice Address - Street 1:1102 A1A N STE 203
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4098
Practice Address - Country:US
Practice Address - Phone:904-569-6875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH24497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health