Provider Demographics
NPI:1144405960
Name:IRENE STACY CMHC
Entity Type:Organization
Organization Name:IRENE STACY CMHC
Other - Org Name:D&A TARGETED CASE MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:724-287-0791
Mailing Address - Street 1:112 HILLVUE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-3498
Mailing Address - Country:US
Mailing Address - Phone:724-287-0791
Mailing Address - Fax:724-287-2730
Practice Address - Street 1:112 HILLVUE DRIVE
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-3498
Practice Address - Country:US
Practice Address - Phone:724-287-0791
Practice Address - Fax:724-287-2730
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IRENE STACY CMHC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101013251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100003515 0114Medicaid