Provider Demographics
NPI:1952520231
Name:BRUCE-FREDERIKSEN, STACY ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ELIZABETH
Last Name:BRUCE-FREDERIKSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 BEE CAVE RD
Mailing Address - Street 2:SUITE 507
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6775
Mailing Address - Country:US
Mailing Address - Phone:512-228-7509
Mailing Address - Fax:
Practice Address - Street 1:3355 BEE CAVE RD
Practice Address - Street 2:SUITE 507
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6775
Practice Address - Country:US
Practice Address - Phone:512-228-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX31139OtherLSCW LICENSE NUMBER