Provider Demographics
NPI:1710540422
Name:STACY, TIMOTHY KYLE (CDCA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:KYLE
Last Name:STACY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2347
Mailing Address - Country:US
Mailing Address - Phone:740-656-8015
Mailing Address - Fax:
Practice Address - Street 1:46 E WATER ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2544
Practice Address - Country:US
Practice Address - Phone:740-656-8015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH169687101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)