Provider Demographics
NPI:1144732264
Name:STACY WRIGHT
Entity type:Organization
Organization Name:STACY WRIGHT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, HSPP
Authorized Official - Phone:219-714-7147
Mailing Address - Street 1:5505 S COUNTY ROAD 475 E
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:IN
Mailing Address - Zip Code:47383-9678
Mailing Address - Country:US
Mailing Address - Phone:219-714-7147
Mailing Address - Fax:219-627-1887
Practice Address - Street 1:5505 S COUNTY ROAD 475 E
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:IN
Practice Address - Zip Code:47383-9678
Practice Address - Country:US
Practice Address - Phone:219-714-7147
Practice Address - Fax:219-627-1887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
IN20041886A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN669102OtherBEACON HEALTH OPTIONS
IN000000834190OtherANTHEM BLUE CROSS BLUE SHIELD
IN200813850AMedicaid