Provider Demographics
NPI:1831960764
Name:GERSON, STACY R (LPC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:GERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 E COLT CT
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1330
Mailing Address - Country:US
Mailing Address - Phone:520-405-5211
Mailing Address - Fax:
Practice Address - Street 1:1631 E GUADALUPE RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3935
Practice Address - Country:US
Practice Address - Phone:480-409-5641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC22304101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional