Basic Information
| Provider Information | |||||||||
| NPI: | 1568650414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLEY | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNCAN | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2803 AKRON RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446917904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
| FaxNumber: | 3302023878 | ||||||||
| Practice Location | |||||||||
| Address1: | 17606 COSHOCTON RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430509218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403970533 | ||||||||
| FaxNumber: | 7403971368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I0500063 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.