Healthcare Provider Details

I. General information

NPI: 1073248357
Provider Name (Legal Business Name): STACI DETWILER MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 E GREENWAY RD STE 100
PHOENIX AZ
85032-4805
US

IV. Provider business mailing address

3334 E GELDING DR
PHOENIX AZ
85032-5352
US

V. Phone/Fax

Practice location:
  • Phone: 480-674-9220
  • Fax: 480-674-9231
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-22553
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: