Provider Demographics
NPI:1477792380
Name:GILLETTE, STACY (MS, PCC)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:MS, PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 E STROOP RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3245
Mailing Address - Country:US
Mailing Address - Phone:937-294-6004
Mailing Address - Fax:937-294-9053
Practice Address - Street 1:529 E STROOP RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-3245
Practice Address - Country:US
Practice Address - Phone:937-294-6004
Practice Address - Fax:937-294-9053
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0500434101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health