=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144417593
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY ANNETTE COURSON LBSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4241 SUMMERHILL RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-793-7561
-----------------------------------------------------
Fax | 903-793-7569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 COLLEGE DR
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-793-7561
-----------------------------------------------------
Fax | 903-793-7569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 40125
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------