Provider Demographics
NPI:1205532793
Name:PIKE, STACY LAINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:LAINE
Last Name:PIKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12574 FLAGLER CENTER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12574 FLAGLER CENTER BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-2615
Practice Address - Country:US
Practice Address - Phone:904-325-9276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11498103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical