Provider Demographics
NPI:1912175662
Name:VANZANT, STACI L (LCSW)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:L
Last Name:VANZANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 S EMERSON AVE STE 141
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1940
Mailing Address - Country:US
Mailing Address - Phone:765-315-9977
Mailing Address - Fax:
Practice Address - Street 1:438 S EMERSON AVE STE 141
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1940
Practice Address - Country:US
Practice Address - Phone:765-315-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005480A104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01094109Medicare PIN
IN344840A5Medicare PIN
INM400059862Medicare PIN