Basic Information
| Provider Information | |||||||||
| NPI: | 1740787886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACY | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | |||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 741 SCHOLL RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197561717 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 741 SCHOLL RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197561717 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2018 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 106S00000X | Y |
No ID Information.