Provider Demographics
NPI:1629876743
Name:WALL, STACY (MSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MAYOR LN
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:DE
Mailing Address - Zip Code:19943-9220
Mailing Address - Country:US
Mailing Address - Phone:646-623-3535
Mailing Address - Fax:
Practice Address - Street 1:123 MAYOR LN
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:DE
Practice Address - Zip Code:19943-9220
Practice Address - Country:US
Practice Address - Phone:646-623-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health