=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174181440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY MYERS LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 08/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 E 116TH ST STE 112
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-3572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-804-4540
-----------------------------------------------------
Fax | 317-755-0676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 631 NUTTAL ST
-----------------------------------------------------
City | WESTFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46074-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-500-3624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 39003539A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 39003539A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------