Provider Demographics
NPI:1336547546
Name:POFFENBARGER, STACY JO (CAP)
Entity Type:Individual
Prefix:
First Name:STACY JO
Middle Name:
Last Name:POFFENBARGER
Suffix:
Gender:F
Credentials:CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 SELKIRK STREET
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405
Mailing Address - Country:US
Mailing Address - Phone:561-398-7294
Mailing Address - Fax:
Practice Address - Street 1:726 SELKIRK ST
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-3136
Practice Address - Country:US
Practice Address - Phone:561-398-7294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6063101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)