Provider Demographics
NPI:1457308074
Name:QUINT, STACY (PSYD)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:QUINT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 PEACH GROVE LN
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:TN
Mailing Address - Zip Code:37191-9354
Mailing Address - Country:US
Mailing Address - Phone:812-454-4884
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-412-1251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041873A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200450480Medicaid
IN000000300322OtherANTHEM PROVIDER NUMBER
IN585677000OtherMAGELLAN HEALTH PROVIDER