Healthcare Provider Details

I. General information

NPI: 1104829589
Provider Name (Legal Business Name): STACY E MASTEN M.S.W., L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 AINSWORTH DR STE 105
PRESCOTT AZ
86301-1624
US

IV. Provider business mailing address

PO BOX 486
HUMBOLDT AZ
86329-0486
US

V. Phone/Fax

Practice location:
  • Phone: 928-777-0919
  • Fax: 928-777-8897
Mailing address:
  • Phone: 928-777-0919
  • Fax: 928-777-8897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW3469
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: