Healthcare Provider Details

I. General information

NPI: 1851077242
Provider Name (Legal Business Name): STACEY MARKELONIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 S SAINT CLAIR ST
PAINESVILLE OH
44077-3421
US

IV. Provider business mailing address

134 S SAINT CLAIR ST
PAINESVILLE OH
44077-3421
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-0678
  • Fax:
Mailing address:
  • Phone: 440-255-0678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA185167
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.003367
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: