Provider Demographics
NPI:1356406060
Name:STACY, SCOTT C (PSYD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:C
Last Name:STACY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 W 6TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3607
Mailing Address - Country:US
Mailing Address - Phone:785-856-8218
Mailing Address - Fax:785-841-8781
Practice Address - Street 1:4321 W 6TH ST STE B
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3607
Practice Address - Country:US
Practice Address - Phone:785-856-8218
Practice Address - Fax:785-841-8281
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1075103TA0400X, 103TB0200X, 103TF0200X, 103TP2701X, 103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP14357Medicare UPIN
KS119868Medicare ID - Type Unspecified