Healthcare Provider Details

I. General information

NPI: 1710211461
Provider Name (Legal Business Name): STACEY LYNETTE BANKSTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY LYNETTE STEVENS LCSW

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 WEST POPLAR
ROGERS AR
72756-4249
US

IV. Provider business mailing address

614 E EMMA AVENUE SUITE 300
SPRINGDALE AR
72764-4469
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-9235
  • Fax: 479-631-0374
Mailing address:
  • Phone: 479-751-7417
  • Fax: 479-751-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7482-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: