Provider Demographics
NPI:1396335790
Name:MICELI, STACY ANN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:MICELI
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 1:10554 W CORTEZ CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-1517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4125 N 124TH ST STE AANDB
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-1837
Practice Address - Country:US
Practice Address - Phone:920-857-9041
Practice Address - Fax:920-857-3366
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WI1-25-80340103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty