Provider Demographics
NPI:1073396149
Name:CARLTON, STACEY RENEE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:CARLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:RENEE
Other - Last Name:CARLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 E 45TH ST STE 320
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44127-1091
Mailing Address - Country:US
Mailing Address - Phone:216-417-1289
Mailing Address - Fax:
Practice Address - Street 1:3100 E 45TH ST STE 320
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1091
Practice Address - Country:US
Practice Address - Phone:216-417-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health