=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659875037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY MCCUTCHAN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2018
-----------------------------------------------------
Last Update Date | 03/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 E UNIVERSITY AVE
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-630-7751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 E UNIVERSITY AVE
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-630-7751
-----------------------------------------------------
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 | 68509
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------