Basic Information
| Provider Information | |||||||||
| NPI: | 1720108079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STERN | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.M.H.C. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337601952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | 7273222150 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337601952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | 7273222150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 01/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH10487 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 004330100 | 05 | FL | MEDICAID |