Healthcare Provider Details

I. General information

NPI: 1588814461
Provider Name (Legal Business Name): STACY ANN CROUCH MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY ANN LICKLEY MSW, LCSW

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

697 PRO-MED LN
CARMEL IN
46032-5323
US

IV. Provider business mailing address

9615 E 148TH ST SUITE 1
NOBLESVILLE IN
46060-4360
US

V. Phone/Fax

Practice location:
  • Phone: 317-574-1254
  • Fax: 317-674-0060
Mailing address:
  • Phone: 317-587-0500
  • Fax: 317-674-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006183A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: