Provider Demographics
NPI:1184095804
Name:ROBINSON, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ROBINSON
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 1:17 FOSTER ST UNIT 13
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5974
Mailing Address - Country:US
Mailing Address - Phone:561-516-4404
Mailing Address - Fax:
Practice Address - Street 1:17 FOSTER ST UNIT 13
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5974
Practice Address - Country:US
Practice Address - Phone:561-516-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker