Provider Demographics
NPI:1154009272
Name:CHRISTENSEN, STACEY C
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:C
Last Name:CHRISTENSEN
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 1:3380 BEAR POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-7739
Mailing Address - Country:US
Mailing Address - Phone:937-844-9316
Mailing Address - Fax:
Practice Address - Street 1:131 OAK MEADOW DR STE 102
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-9812
Practice Address - Country:US
Practice Address - Phone:614-835-6068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1101196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health