Provider Demographics
NPI:1245270800
Name:DAVISON, STACY MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:DAVISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-2321
Mailing Address - Country:US
Mailing Address - Phone:315-243-2475
Mailing Address - Fax:
Practice Address - Street 1:600 WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-2321
Practice Address - Country:US
Practice Address - Phone:315-243-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072880-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9306086543000/010Medicare ID - Type UnspecifiedCCN