Basic Information
| Provider Information | |||||||||
| NPI: | 1043325541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UNDERWOOD | ||||||||
| FirstName: | STACY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 N 7TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850143653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022797655 | ||||||||
| FaxNumber: | 6022641806 | ||||||||
| Practice Location | |||||||||
| Address1: | 1255 W BASELINE RD | ||||||||
| Address2: | SUITE B258 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852025820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808200825 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 074959 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 163W00000X | 5 | NY | N | Nursing Service Providers | Registered Nurse | 363LP0808X | F401243-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP3830 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.