Provider Demographics
NPI:1821572124
Name:THOMAS, STACEY E
Entity Type:Individual
Prefix:MR
First Name:STACEY
Middle Name:E
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 GOLETA AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1327
Mailing Address - Country:US
Mailing Address - Phone:330-787-9180
Mailing Address - Fax:234-254-8413
Practice Address - Street 1:209 W WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-1866
Practice Address - Country:US
Practice Address - Phone:330-787-9180
Practice Address - Fax:234-254-8413
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty