Provider Demographics
NPI:1396229027
Name:STACKHOUSE, MICHELLE LOIS (PEER SUPPORT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LOIS
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:PEER SUPPORT
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:LOIS
Other - Last Name:BEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PEER SUPPORT
Mailing Address - Street 1:5736 EAST BLVD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1655
Mailing Address - Country:US
Mailing Address - Phone:330-806-1953
Mailing Address - Fax:
Practice Address - Street 1:5736 EAST BLVD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-1655
Practice Address - Country:US
Practice Address - Phone:330-806-1953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00030175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-1575839OtherICAN, INC.