Provider Demographics
NPI:1417413303
Name:STOTTS, THERESA FAYE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:FAYE
Last Name:STOTTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 RUSSELL RD.
Mailing Address - Street 2:STE 93
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728
Mailing Address - Country:US
Mailing Address - Phone:270-384-1736
Mailing Address - Fax:
Practice Address - Street 1:933 RUSSELL RD.
Practice Address - Street 2:STE 93
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728
Practice Address - Country:US
Practice Address - Phone:270-384-1736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
KY276256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100807930Medicaid