Provider Demographics
NPI:1124495098
Name:CARPENTER, STACI JO (MSW, LSW)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:JO
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:MENIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, CSW
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:
Practice Address - Street 1:840 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1768
Practice Address - Country:US
Practice Address - Phone:866-233-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1903345104100000X
KY7394104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0334428Medicaid
KY7100620870Medicaid
OHS.1903345OtherLICENSED SOCIAL WORKER