Provider Demographics
NPI:1841010915
Name:OVERSTREET, STACEY MATTHEWS
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MATTHEWS
Last Name:OVERSTREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 S PEAR ORCHARD RD APT 1708
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4219
Mailing Address - Country:US
Mailing Address - Phone:601-842-0645
Mailing Address - Fax:
Practice Address - Street 1:1437 OLD SQUARE RD STE 101
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5533
Practice Address - Country:US
Practice Address - Phone:601-977-9353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP1214101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty