Provider Demographics
NPI:1205030657
Name:STUECKER, CATHRYN
Entity type:Individual
Prefix:
First Name:CATHRYN
Middle Name:
Last Name:STUECKER
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 1:2400 MARYMOUNT CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40242-6431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2225 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-1003
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:502-589-8771
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0678101YM0800X
KY1176101YP2500X
KY103054101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100285220Medicaid