Provider Demographics
NPI:1417350547
Name:EMMERT, STACEY (BCBA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:EMMERT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5597 N LYE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-7831
Mailing Address - Country:US
Mailing Address - Phone:765-366-1895
Mailing Address - Fax:
Practice Address - Street 1:5597 N LYE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-7831
Practice Address - Country:US
Practice Address - Phone:765-366-1895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst