Provider Demographics
NPI:1023290236
Name:SUMMERS, STACEY A
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WALNUT ST STE 1017
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2906
Mailing Address - Country:US
Mailing Address - Phone:215-564-0488
Mailing Address - Fax:215-564-1245
Practice Address - Street 1:1601 WALNUT ST STE 1017
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2906
Practice Address - Country:US
Practice Address - Phone:215-564-0488
Practice Address - Fax:215-564-1245
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015838103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017489680001Medicaid