Provider Demographics
NPI:1588814461
Name:CROUCH, STACY ANN (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANN
Last Name:CROUCH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:LICKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:9615 E 148TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4360
Mailing Address - Country:US
Mailing Address - Phone:317-587-0500
Mailing Address - Fax:317-674-0060
Practice Address - Street 1:697 PRO-MED LN
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5323
Practice Address - Country:US
Practice Address - Phone:317-574-1254
Practice Address - Fax:317-674-0060
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IN34006183A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000705772OtherANTHEM BCBS
IN945920066Medicare PIN
IN000000705772OtherANTHEM BCBS