=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457308074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY QUINT PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2006
-----------------------------------------------------
Last Update Date | 05/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 JOEL DR
-----------------------------------------------------
City | FORT CAMPBELL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42223-5318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-412-1251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2608 PEACH GROVE LN
-----------------------------------------------------
City | WOODLAWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37191-9354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-454-4884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 20041873A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------