MEDICARE: STACY E MASTEN M.S.W., L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW3469	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104829589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY E MASTEN M.S.W., L.C.S.W.

Provider Business Mailing Address
First Line	:	PO BOX 486
Second Line	:
City	:	HUMBOLDT
State	:	AZ
Zip	:	86329-0486
Country	:	US
Telephone Number	:	928-777-0919
Fax Number	:	928-777-8897

Provider Business Practice Location Address
First Line	:	804 AINSWORTH DR
Second Line	:	STE 105
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-1624
Country	:	US
Telephone Number	:	928-777-0919
Fax Number	:	928-777-8897

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	09/28/2007

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