Provider Demographics
NPI:1275009151
Name:STACY, KENNEDY ALANAH
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:ALANAH
Last Name:STACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:
Other - Last Name:HARLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 RAMONA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-4317
Mailing Address - Country:US
Mailing Address - Phone:937-763-9226
Mailing Address - Fax:
Practice Address - Street 1:3449 NEWMARK DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-5426
Practice Address - Country:US
Practice Address - Phone:937-637-9374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician