Provider Demographics
NPI:1720523822
Name:SHIVERS, STACIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 QUIMBY ST STE 6
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-5106
Mailing Address - Country:US
Mailing Address - Phone:973-630-8702
Mailing Address - Fax:
Practice Address - Street 1:111 QUIMBY ST STE 6
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-5106
Practice Address - Country:US
Practice Address - Phone:973-630-8702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ153-065103TC0700X
NJ35SI00583600103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical