Provider Demographics
NPI:1952618241
Name:WHITTEMORE, STACEY SALLEY (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:SALLEY
Last Name:WHITTEMORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:SALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3349 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-9000
Mailing Address - Country:US
Mailing Address - Phone:954-885-9500
Mailing Address - Fax:954-885-9444
Practice Address - Street 1:1125 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4351
Practice Address - Country:US
Practice Address - Phone:985-727-4075
Practice Address - Fax:954-885-9444
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA108401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical