Healthcare Provider Details

I. General information

NPI: 1134397128
Provider Name (Legal Business Name): STACEY DAVIS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 ANASTASIA BLVD
ST AUGUSTINE FL
32080-4508
US

IV. Provider business mailing address

307 TUMBLED STONE WAY
ST AUGUSTINE FL
32086-0230
US

V. Phone/Fax

Practice location:
  • Phone: 904-834-1366
  • Fax:
Mailing address:
  • Phone: 352-870-8173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7649
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: