Provider Demographics
NPI:1801682638
Name:MCCALL-BUSH, STACEY MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:MCCALL-BUSH
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 WHITE BRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-9707
Mailing Address - Country:US
Mailing Address - Phone:607-749-0342
Mailing Address - Fax:607-749-0342
Practice Address - Street 1:24 COPELAND AVE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077-1529
Practice Address - Country:US
Practice Address - Phone:607-749-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
127103104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker