MEDICARE: DR. STACY LAINE PIKE PSY.D.

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	103TC0700X	Clinical Psychologist	PY11498	FL

General Provider Information

NPI Number	:	1205532793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY LAINE PIKE PSY.D.

Provider Business Mailing Address
First Line	:	12574 FLAGLER CENTER BLVD STE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2615
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12574 FLAGLER CENTER BLVD STE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2615
Country	:	US
Telephone Number	:	904-325-9276
Fax Number	:

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

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	03/29/2023

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