Stacey Lee Blase, PHD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

003696 Issued in CT

Practice address

21 Sherman CT
Fairfield, CT 06824-5825

Phone

(203) 533-9496

NPI assigned

Jul 2, 2012

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Sep 17, 2021 through Sep 17, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1341187200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1644105600000",
    "number": "1487918660",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21 SHERMAN CT",
            "city": "FAIRFIELD",
            "state": "CT",
            "postal_code": "068245825",
            "telephone_number": "203-533-9496"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21 SHERMAN CT",
            "city": "FAIRFIELD",
            "state": "CT",
            "postal_code": "068245825",
            "telephone_number": "203-533-9496"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "34 York St",
            "address_purpose": "LOCATION",
            "city": "Guilford",
            "state": "CT",
            "postal_code": "064372473",
            "country_code": "US",
            "telephone_number": "203-533-9496",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLASE",
        "first_name": "STACEY",
        "middle_name": "LEE",
        "credential": "PHD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2012-07-02",
        "last_updated": "2022-02-06",
        "certification_date": "2022-02-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NY",
            "license": "021811",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CT",
            "license": "003696",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Janette A. Black, D.D.S.
• Rachel Black
• Emily Blair, M.D., D.O.
• Heather Blair, SLP
• Emil J. Blanco, MD
• Seth Barak Blattman, M.D.
• Barbara Jacqueline Blau, LPC, NCC, JD, MA
• Nicholas Alfred Blondin, M.D.
• Katherine Alexis Bloom, M.D.
• Todd Evan Bloom, M.S., D.D.S.

• Clinical Psychologist in Fairfield, CT
• Providers in Fairfield, CT by specialty
• Clinical Psychologist in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.