Provider Demographics
NPI:1376082719
Name:STACY, TYLER (LPC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:STACY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 I 55 N STE 208
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5931
Mailing Address - Country:US
Mailing Address - Phone:601-405-7440
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N STE 208
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5931
Practice Address - Country:US
Practice Address - Phone:601-405-7440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6721101Y00000X
MS2366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor