Basic Information
| Provider Information | |||||||||
| NPI: | 1588814461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROUCH | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LICKLEY | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9615 E 148TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460604360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175870500 | ||||||||
| FaxNumber: | 3176740060 | ||||||||
| Practice Location | |||||||||
| Address1: | 697 PRO-MED LN | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460325323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175741254 | ||||||||
| FaxNumber: | 3176740060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2008 | ||||||||
| LastUpdateDate: | 08/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 34006183A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000705772 | 01 | IN | ANTHEM BCBS | OTHER |