Provider Demographics
NPI:1790367746
Name:KIRKHAM, STACY (LCADC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KIRKHAM
Suffix:
Gender:
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BERGER RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-4522
Mailing Address - Country:US
Mailing Address - Phone:270-441-0030
Mailing Address - Fax:
Practice Address - Street 1:220 BERGER RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4522
Practice Address - Country:US
Practice Address - Phone:270-441-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38328101YA0400X
IL150112934104100000X
101Y00000X
KY297211101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor