Provider Demographics
NPI:1336589811
Name:MACKIE, STACIA ANN (MS)
Entity Type:Individual
Prefix:MRS
First Name:STACIA
Middle Name:ANN
Last Name:MACKIE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 BARTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3028
Mailing Address - Country:US
Mailing Address - Phone:321-368-7523
Mailing Address - Fax:
Practice Address - Street 1:1022 BARTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3028
Practice Address - Country:US
Practice Address - Phone:321-368-7523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health