Provider Demographics
NPI:1710596010
Name:CRUSE, STACEY DEANN (PASTORAL COUNSELOR)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DEANN
Last Name:CRUSE
Suffix:
Gender:F
Credentials:PASTORAL COUNSELOR
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:DEANN
Other - Last Name:CRUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICENSED PASTORAL CO
Mailing Address - Street 1:71 CAVALIER BLVD #303
Mailing Address - Street 2:
Mailing Address - City:FLORANCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042
Mailing Address - Country:US
Mailing Address - Phone:859-282-0204
Mailing Address - Fax:859-282-0361
Practice Address - Street 1:71 CAVALIER BLVD #303
Practice Address - Street 2:
Practice Address - City:FLORANCE
Practice Address - State:KY
Practice Address - Zip Code:41042
Practice Address - Country:US
Practice Address - Phone:859-282-0204
Practice Address - Fax:859-282-0361
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY263317101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100627070Medicaid