Provider Demographics
NPI:1326526476
Name:STACY, LEEANN F (LCDC II, BA, QMHS)
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:F
Last Name:STACY
Suffix:
Gender:F
Credentials:LCDC II, BA, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 DAVE AVE APT 701
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-2724
Mailing Address - Country:US
Mailing Address - Phone:513-439-0024
Mailing Address - Fax:
Practice Address - Street 1:2611 WAYNE AVE BLDG 61
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1833
Practice Address - Country:US
Practice Address - Phone:937-256-7801
Practice Address - Fax:937-641-8517
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150980101YA0400X
OHLCDCII.161673101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0257397Medicaid