Basic Information
| Provider Information | |||||||||
| NPI: | 1861545642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNETT | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RYAN | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5050 MADISON RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452271491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132722800 | ||||||||
| FaxNumber: | 5135277355 | ||||||||
| Practice Location | |||||||||
| Address1: | 6608 STONEGATE DR | ||||||||
| Address2: | |||||||||
| City: | GUILFORD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470229753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136736287 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34000078A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | I.1502015 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.