Provider Demographics
NPI:1457586570
Name:RISE, STACEY CARYN (LMSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:CARYN
Last Name:RISE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 NORWICH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8423
Mailing Address - Country:US
Mailing Address - Phone:631-271-6567
Mailing Address - Fax:631-427-0570
Practice Address - Street 1:71 NORWICH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-8423
Practice Address - Country:US
Practice Address - Phone:631-271-6567
Practice Address - Fax:631-427-0570
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061331-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical