Provider Demographics
NPI:1902084551
Name:ATKINS, STACEY L (MC)
Entity Type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:L
Last Name:ATKINS
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11112 E SANTINO AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2610
Mailing Address - Country:US
Mailing Address - Phone:480-540-0265
Mailing Address - Fax:
Practice Address - Street 1:288 N IRONWOOD DR
Practice Address - Street 2:SUITE 110
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-3830
Practice Address - Country:US
Practice Address - Phone:480-982-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11357101YA0400X
AZLPC13473101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346214Medicaid