Healthcare Provider Details

I. General information

NPI: 1376731943
Provider Name (Legal Business Name): STACEY JO CHERRY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS STACEY JO TIBBETTS

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 COTTAGE RD
NORTHFIELD ME
04654
US

IV. Provider business mailing address

PO BOX 203
MACHIAS ME
04654-0203
US

V. Phone/Fax

Practice location:
  • Phone: 207-598-8258
  • Fax:
Mailing address:
  • Phone: 207-598-8258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL3276
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: