Provider Demographics
NPI:1366779902
Name:DAVIS, STACY MARSHALL (MACC, LPC)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARSHALL
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MACC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-3739
Mailing Address - Country:US
Mailing Address - Phone:864-706-7555
Mailing Address - Fax:
Practice Address - Street 1:250 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3009
Practice Address - Country:US
Practice Address - Phone:864-585-0366
Practice Address - Fax:864-583-3136
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
SC7475101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC121328Medicaid