Healthcare Provider Details

I. General information

NPI: 1790367746
Provider Name (Legal Business Name): STACY KIRKHAM LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 03/14/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BERGER RD
PADUCAH KY
42003-4522
US

IV. Provider business mailing address

220 BERGER RD
PADUCAH KY
42003-4522
US

V. Phone/Fax

Practice location:
  • Phone: 270-441-0030
  • Fax:
Mailing address:
  • Phone: 270-441-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number38328
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number297211
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150112934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: