Provider Demographics
NPI:1679757181
Name:BRAULT, STACY MARIE (BSW)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:MARIE
Last Name:BRAULT
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:MS
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:BRAULT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSW
Mailing Address - Street 1:PO BOX 231724
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-1724
Mailing Address - Country:US
Mailing Address - Phone:907-349-8157
Mailing Address - Fax:907-222-1336
Practice Address - Street 1:8021 CLEAR HAVEN CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3272
Practice Address - Country:US
Practice Address - Phone:907-349-8157
Practice Address - Fax:907-222-1336
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK746362171M00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management