Healthcare Provider Details

I. General information

NPI: 1356406060
Provider Name (Legal Business Name): SCOTT C. STACY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 W 6TH ST STE B
LAWRENCE KS
66049-3607
US

IV. Provider business mailing address

4321 W 6TH ST STE B
LAWRENCE KS
66049-3607
US

V. Phone/Fax

Practice location:
  • Phone: 785-856-8218
  • Fax: 785-841-8281
Mailing address:
  • Phone: 785-856-8218
  • Fax: 785-841-8781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1075
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number1075
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1075
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1075
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number1075
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number1075
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: