Provider Demographics
NPI:1144909268
Name:GURGANUS, STACY LYNN (LICSW,LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:GURGANUS
Suffix:
Gender:F
Credentials:LICSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 SUGARMILL CIR
Mailing Address - Street 2:
Mailing Address - City:AXIS
Mailing Address - State:AL
Mailing Address - Zip Code:36505-4631
Mailing Address - Country:US
Mailing Address - Phone:251-689-4492
Mailing Address - Fax:
Practice Address - Street 1:3929 AIRPORT BLVD, BUILDING 3, SUITE 307
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609
Practice Address - Country:US
Practice Address - Phone:251-689-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1581C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical