Provider Demographics
NPI:1609375724
Name:THRUSH, STACEY A (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:A
Last Name:THRUSH
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 W GORDONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-9151
Mailing Address - Country:US
Mailing Address - Phone:989-600-0995
Mailing Address - Fax:
Practice Address - Street 1:2355 DELTA RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-9340
Practice Address - Country:US
Practice Address - Phone:989-778-2272
Practice Address - Fax:989-778-2276
Is Sole Proprietor?:No
Enumeration Date:2018-02-04
Last Update Date:2018-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801099785104100000X, 1041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool