Provider Demographics
NPI:1235694753
Name:THOMAS, STACEY R
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:THOMAS
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 1:11 W MONUMENT AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1274
Mailing Address - Country:US
Mailing Address - Phone:937-461-4300
Mailing Address - Fax:937-461-0443
Practice Address - Street 1:1404 GASCHO DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-3305
Practice Address - Country:US
Practice Address - Phone:937-252-7500
Practice Address - Fax:937-252-3971
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1326012360OtherAGENCY NPI