Provider Demographics
NPI:1376731943
Name:CHERRY, STACEY JO (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:JO
Last Name:CHERRY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:JO
Other - Last Name:TIBBETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-1165
Mailing Address - Country:US
Mailing Address - Phone:207-255-4100
Mailing Address - Fax:207-255-4100
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-1165
Practice Address - Country:US
Practice Address - Phone:207-255-4100
Practice Address - Fax:207-255-4100
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1376731943OtherMAINECARE