Provider Demographics
NPI:1225457005
Name:CHARMOY, STACEY (MA BCBA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CHARMOY
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51322
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-5622
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-9283
Practice Address - Street 1:18550 W MILLBURN RD
Practice Address - Street 2:
Practice Address - City:OLD MILL CREEK
Practice Address - State:IL
Practice Address - Zip Code:60083-9248
Practice Address - Country:US
Practice Address - Phone:270-777-9283
Practice Address - Fax:270-777-9283
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-14-15388103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst