Provider Demographics
NPI:1770920522
Name:BISGROVE, STACY MICHELLE (LMHC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MICHELLE
Last Name:BISGROVE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 W DOMINICK ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-5855
Mailing Address - Country:US
Mailing Address - Phone:315-272-2730
Mailing Address - Fax:315-337-0675
Practice Address - Street 1:199 W DOMINICK ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-272-2730
Practice Address - Fax:315-337-0675
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005578-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health