Provider Demographics
NPI:1295987162
Name:MARTIN, STACY A (MDIV, MSW, LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MDIV, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 MCLAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-3662
Mailing Address - Country:US
Mailing Address - Phone:870-495-1990
Mailing Address - Fax:870-495-1994
Practice Address - Street 1:2005 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3662
Practice Address - Country:US
Practice Address - Phone:870-495-1990
Practice Address - Fax:870-495-1994
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0069381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical