Provider Demographics
NPI:1164141263
Name:BRENLY, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BRENLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 BLACKLICK EASTERN RD
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-8235
Mailing Address - Country:US
Mailing Address - Phone:740-319-4445
Mailing Address - Fax:
Practice Address - Street 1:35740 COUNTY ROAD 402
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:OH
Practice Address - Zip Code:43844-9500
Practice Address - Country:US
Practice Address - Phone:740-502-0397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator