Basic Information
Provider Information | |||||||||
NPI: | 1245381383 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DENNIS | ||||||||
FirstName: | STACEY | ||||||||
MiddleName: | KATHERINE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SIESSER | ||||||||
OtherFirstName: | STACEY | ||||||||
OtherMiddleName: | KATHERINE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSW, LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2300 RAMSEY ST | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283013856 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9104882120 | ||||||||
FaxNumber: | 9104825099 | ||||||||
Practice Location | |||||||||
Address1: | 2300 RAMSEY ST | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283013856 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9104882120 | ||||||||
FaxNumber: | 9104825099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 07/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.