Healthcare Provider Details

I. General information

NPI: 1902084551
Provider Name (Legal Business Name): STACEY L. ATKINS M.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 N IRONWOOD DR SUITE 110
APACHE JUNCTION AZ
85120-3830
US

IV. Provider business mailing address

11112 E SANTINO AVE
MESA AZ
85212-2610
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-2356
  • Fax:
Mailing address:
  • Phone: 480-540-0265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-11357
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC13473
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: