Provider Demographics
NPI:1255884193
Name:KIRKSEY, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KIRKSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 BERYL TRL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3965
Mailing Address - Country:US
Mailing Address - Phone:937-818-5309
Mailing Address - Fax:
Practice Address - Street 1:1070 BERYL TRL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-3965
Practice Address - Country:US
Practice Address - Phone:937-818-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUD1014166103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool