Basic Information
| Provider Information | |||||||||
| NPI: | 1093858722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCUNE | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MINIX | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 209 N MAYSVILLE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8594988160 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 N MAYSVILLE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403531179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8594988160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1055 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 7100265570 | 05 | KY | MEDICAID |