Healthcare Provider Details

I. General information

NPI: 1053729632
Provider Name (Legal Business Name): STACEY ABRAHAM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MASSACHUSETTS AVE NW
WASHINGTON DC
20001-1431
US

IV. Provider business mailing address

2208 MOUNTAIN AVE
SCOTCH PLAINS NJ
07076-1304
US

V. Phone/Fax

Practice location:
  • Phone: 301-262-2270
  • Fax: 410-569-0094
Mailing address:
  • Phone: 301-262-2270
  • Fax: 410-569-0094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50079488
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: