Provider Demographics
NPI:1114727591
Name:STOLLER, MACY LANA
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:LANA
Last Name:STOLLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 ALABAMA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4405
Mailing Address - Country:US
Mailing Address - Phone:260-246-7239
Mailing Address - Fax:
Practice Address - Street 1:2131 ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4405
Practice Address - Country:US
Practice Address - Phone:260-246-7239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-15
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN4840-21-0184106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician