Provider Demographics
NPI:1295264448
Name:YOUNG, STACY MARIE
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:67160 DAILEY RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9660
Mailing Address - Country:US
Mailing Address - Phone:269-845-0069
Mailing Address - Fax:
Practice Address - Street 1:32652 KNO DRIVE
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047
Practice Address - Country:US
Practice Address - Phone:269-982-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016096101YP2500X, 101Y00000X
MI4101006741106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist