Provider Demographics
NPI:1871561407
Name:CONWAY, STACEY MICHELLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MICHELLE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-3627
Mailing Address - Country:US
Mailing Address - Phone:845-494-1149
Mailing Address - Fax:
Practice Address - Street 1:154 LAKE DR
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-3627
Practice Address - Country:US
Practice Address - Phone:914-922-1042
Practice Address - Fax:914-922-1153
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071494-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN38U11Medicare ID - Type UnspecifiedPROVIDER NUMBER