Provider Demographics
NPI:1528880234
Name:MERCILUS, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MERCILUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 NW 56TH AVE APT D305
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-1356
Mailing Address - Country:US
Mailing Address - Phone:954-866-1440
Mailing Address - Fax:
Practice Address - Street 1:4701 N FEDERAL HWY STE 460
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-6591
Practice Address - Country:US
Practice Address - Phone:954-866-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-379415106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician