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General NPI Number Information
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NPI Number | 1962047548
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Entity Type | Individual
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Provider Name | STACYE ELIZABETH MCQUEEN
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Gender | Female
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Dates
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Enumeration Date | 11/07/2019
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Last Update Date | 11/07/2019
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Provider Practice Location Address
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Address Line | 104 E MAIN ST STE 200
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City | INEZ
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State | KY
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Zip | 41224-8928
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Country | US
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Telephone | 606-298-7633
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 158
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City | PAINTSVILLE
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State | KY
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Zip | 41240-0158
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Country | US
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Telephone | 606-792-1381
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 139343
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 252812
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License Number State | KY
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