Healthcare Provider Details

I. General information

NPI: 1568782795
Provider Name (Legal Business Name): STACY MARIE MCKINNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W. 10TH ST CRISIS INTERVENTION UNIT
INDIANAPOLS IN
46202-2859
US

IV. Provider business mailing address

PO BOX 637764
CINCINNATI OH
45263-7764
US

V. Phone/Fax

Practice location:
  • Phone: 317-630-8485
  • Fax: 317-630-7616
Mailing address:
  • Phone: 317-880-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006013A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001438A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: