Provider Demographics
NPI:1780408252
Name:DAVIS, STACEY LEE JR
Entity type:Individual
Prefix:MR
First Name:STACEY
Middle Name:LEE
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCMHCA, CRC
Mailing Address - Street 1:1400 CRESCENT GRN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8118
Mailing Address - Country:US
Mailing Address - Phone:919-233-4131
Mailing Address - Fax:
Practice Address - Street 1:1400 CRESCENT GRN
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8118
Practice Address - Country:US
Practice Address - Phone:919-233-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health