Provider Demographics
NPI:1164990495
Name:COGHILL, STACEY J (LMHC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:COGHILL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:J
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1077
Practice Address - Country:US
Practice Address - Phone:317-963-2200
Practice Address - Fax:317-963-1621
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003081A101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300054495Medicaid