1356623979 NPI number — MRS. STACE DEVILLIER FARROW LPC

Table of content: MRS. STACE DEVILLIER FARROW LPC (NPI 1356623979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356623979 NPI number — MRS. STACE DEVILLIER FARROW LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARROW
Provider First Name:
STACE
Provider Middle Name:
DEVILLIER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356623979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3021 S STATE HIGHWAY 16
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78624-9408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-990-7999
Provider Business Mailing Address Fax Number:
830-990-7999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
945 E ASHWOOD LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-1412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-343-7025
Provider Business Practice Location Address Fax Number:
830-990-7999
Provider Enumeration Date:
09/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  16739 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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