Provider Demographics
NPI:1306467477
Name:KILLIAN, STACY JEAN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JEAN
Last Name:KILLIAN
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 1:3636 W HUMPHREY RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-9680
Mailing Address - Country:US
Mailing Address - Phone:810-287-7144
Mailing Address - Fax:
Practice Address - Street 1:608 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1617
Practice Address - Country:US
Practice Address - Phone:989-463-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017388101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional