Provider Demographics
NPI:1710211461
Name:BANKSTON, STACEY LYNETTE (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNETTE
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNETTE
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:614 E EMMA AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4469
Mailing Address - Country:US
Mailing Address - Phone:479-751-7417
Mailing Address - Fax:479-751-4898
Practice Address - Street 1:1233 WEST POPLAR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4249
Practice Address - Country:US
Practice Address - Phone:479-636-9235
Practice Address - Fax:479-631-0374
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7482-C1041C0700X
MO2011040546101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746170GMedicaid