Provider Demographics
NPI:1508817917
Name:WRIGHT, STACY L (PSYD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9150 E. 109TH AVE.
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7686
Mailing Address - Country:US
Mailing Address - Phone:219-406-9423
Mailing Address - Fax:219-627-1887
Practice Address - Street 1:9150 E 109TH AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7686
Practice Address - Country:US
Practice Address - Phone:219-406-9423
Practice Address - Fax:219-627-1887
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041886A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00407223OtherRAILROAD MEDICARE
IN200813850AMedicaid
INQ26954Medicare UPIN
INP00407223OtherRAILROAD MEDICARE