Provider Demographics
NPI:1902561954
Name:RICHARDSON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 JESSIE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-1015
Mailing Address - Country:US
Mailing Address - Phone:740-285-1139
Mailing Address - Fax:
Practice Address - Street 1:14532 ST. RT. 32
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690
Practice Address - Country:US
Practice Address - Phone:740-947-2364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health