MEDICARE: STACIE DAVIS LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

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	:	1982178257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STACIE DAVIS LLC

Provider Business Mailing Address
First Line	:	501 CEDAR RD STE 2C
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23322-5527
Country	:	US
Telephone Number	:	757-574-0303
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 CEDAR RD STE 2C
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23322-5527
Country	:	US
Telephone Number	:	757-574-0303
Fax Number	:	757-574-0102

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	STACIE DAVIS
Credential	:	LPC
Telephone Number	:	757-574-0303

Provider Enumeration Date	:	01/19/2019
Last Update Date	:	01/19/2019

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