Provider Demographics
NPI:1417437039
Name:STANLEY, MICHAEL SCOTT (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:STANLEY
Suffix:
Gender:M
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1347
Mailing Address - Country:US
Mailing Address - Phone:740-578-4824
Mailing Address - Fax:740-578-4821
Practice Address - Street 1:254 PINECREST DR
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1347
Practice Address - Country:US
Practice Address - Phone:740-578-4824
Practice Address - Fax:740-578-4821
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH167042101YA0400X
OHS.2207362104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH320087Medicaid