MEDICARE: STACEY LYNETTE BANKSTON LCSW

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	7482-C	AR

General Provider Information

NPI Number	:	1710211461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY LYNETTE BANKSTON LCSW

Provider Business Mailing Address
First Line	:	614 E EMMA AVENUE
Second Line	:	SUITE 300
City	:	SPRINGDALE
State	:	AR
Zip	:	72764-4469
Country	:	US
Telephone Number	:	479-751-7417
Fax Number	:	479-751-4898

Provider Business Practice Location Address
First Line	:	1233 WEST POPLAR
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72756-4249
Country	:	US
Telephone Number	:	479-636-9235
Fax Number	:	479-631-0374

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

Provider Enumeration Date	:	09/29/2009
Last Update Date	:	09/08/2016

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