Healthcare Provider Details

I. General information

NPI: 1720202674
Provider Name (Legal Business Name): STACEY MARIE GAPPA LCSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70239 BEACH DR
EDWARDSBURG MI
49112-9436
US

IV. Provider business mailing address

70239 BEACH DR
EDWARDSBURG MI
49112-9436
US

V. Phone/Fax

Practice location:
  • Phone: 574-302-6094
  • Fax:
Mailing address:
  • Phone: 574-302-6094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34008919A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801106723
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: