1023339132 NPI number — STACY MICHELLE SYRCLE MD

Table of content: EBONY NICOLE MIDDLETON MSW, LMSW (NPI 1518566801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023339132 NPI number — STACY MICHELLE SYRCLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SYRCLE
Provider First Name:
STACY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1023339132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 735044
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-326-2250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8905 W LINCOLN AVE
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
WEST ALLIS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53227-2468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-978-2229
Provider Business Practice Location Address Fax Number:
414-978-2279
Provider Enumeration Date:
06/14/2010

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: 207V00000X , with the licence number:  67167-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 036-135033 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 036135033 1 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100043207 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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