Provider Demographics
NPI:1629677968
Name:COLE, STACY LYNN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45212-4036
Mailing Address - Country:US
Mailing Address - Phone:513-708-3398
Mailing Address - Fax:
Practice Address - Street 1:2621 VICTORY PKWY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-1754
Practice Address - Country:US
Practice Address - Phone:513-221-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1701681101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health