Provider Demographics
NPI:1457530586
Name:FOSS, STACEY L (LAC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:L
Last Name:FOSS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3368
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-3368
Mailing Address - Country:US
Mailing Address - Phone:970-570-5238
Mailing Address - Fax:844-877-4159
Practice Address - Street 1:2800 CORNERSTONE DR STE 207
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-570-5238
Practice Address - Fax:844-877-4159
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD-142101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)