Provider Demographics
NPI:1477521466
Name:STACY, PAMELA JEAN (LCSW, RN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:STACY
Suffix:
Gender:F
Credentials:LCSW, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:720 N MARR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6660
Practice Address - Country:US
Practice Address - Phone:812-314-3400
Practice Address - Fax:812-376-4875
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH28142163A163W00000X
IN34006033A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse