Provider Demographics
NPI:1326912205
Name:STACY, CLINT JAY (PRSS-SUD)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:JAY
Last Name:STACY
Suffix:
Gender:M
Credentials:PRSS-SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:PANTHER
Mailing Address - State:WV
Mailing Address - Zip Code:24872-0464
Mailing Address - Country:US
Mailing Address - Phone:681-323-8335
Mailing Address - Fax:681-323-8335
Practice Address - Street 1:550 N EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3109
Practice Address - Country:US
Practice Address - Phone:681-323-8335
Practice Address - Fax:681-323-8335
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24-9156175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty