Provider Demographics
NPI:1861545642
Name:CORNETT, STACEY M (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:CORNETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5050 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-1491
Mailing Address - Country:US
Mailing Address - Phone:513-272-2800
Mailing Address - Fax:513-527-7355
Practice Address - Street 1:6608 STONEGATE DR
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:IN
Practice Address - Zip Code:47022-9753
Practice Address - Country:US
Practice Address - Phone:513-673-6287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000078A1041C0700X
OHI.15020151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000200250OtherBLUE SHIELD
IN172160PMedicare ID - Type UnspecifiedMEDICARE