Healthcare Provider Details

I. General information

NPI: 1669853107
Provider Name (Legal Business Name): STACY MACEK MA, AT, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28700 EUCLID AVE ISSENMANN BUILDING
WICKLIFFE OH
44092-2527
US

IV. Provider business mailing address

28700 EUCLID AVE ISSENMANN BUILDING
WICKLIFFE OH
44092-2527
US

V. Phone/Fax

Practice location:
  • Phone: 440-943-7607
  • Fax:
Mailing address:
  • Phone: 440-943-7607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.1000584
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1000584
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1000584
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: