Healthcare Provider Details

I. General information

NPI: 1568726461
Provider Name (Legal Business Name): STACY RICHARDS LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463142 SR 200
YULEE FL
32097-5554
US

IV. Provider business mailing address

463142 SR 200
YULEE FL
32097-5554
US

V. Phone/Fax

Practice location:
  • Phone: 903-758-0596
  • Fax: 903-758-0598
Mailing address:
  • Phone: 904-225-8280
  • Fax: 904-335-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8369
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0101163
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: