Healthcare Provider Details

I. General information

NPI: 1962047548
Provider Name (Legal Business Name): STACYE ELIZABETH MCQUEEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E MAIN ST STE 200
INEZ KY
41224-8928
US

IV. Provider business mailing address

PO BOX 158
PAINTSVILLE KY
41240-0158
US

V. Phone/Fax

Practice location:
  • Phone: 606-298-7633
  • Fax:
Mailing address:
  • Phone: 606-792-1381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number139343
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number252812
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: