Provider Demographics
NPI:1063651065
Name:DOLEN, STACEY BETH (LISW)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:BETH
Last Name:DOLEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 KINGSTONVIEW CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-2495
Mailing Address - Country:US
Mailing Address - Phone:513-502-8264
Mailing Address - Fax:513-233-7340
Practice Address - Street 1:7510 KINGSTONVIEW CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-2495
Practice Address - Country:US
Practice Address - Phone:513-502-8264
Practice Address - Fax:513-233-7340
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.08003671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW35391Medicare UPIN