Provider Demographics
NPI:1548808462
Name:SUSTAITA, STACIE L
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:SUSTAITA
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 1:12106 PALMDATE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77034-3731
Mailing Address - Country:US
Mailing Address - Phone:713-248-5191
Mailing Address - Fax:
Practice Address - Street 1:10851 SCARSDALE BLVD STE 160
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-5737
Practice Address - Country:US
Practice Address - Phone:281-824-1480
Practice Address - Fax:281-220-6407
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX368331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical