Provider Demographics
NPI:1528146560
Name:MCKENZIE-BACA, STACY L (LPCC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:MCKENZIE-BACA
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25708-0390
Mailing Address - Country:US
Mailing Address - Phone:304-429-1088
Mailing Address - Fax:
Practice Address - Street 1:404 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1167
Practice Address - Country:US
Practice Address - Phone:606-889-1602
Practice Address - Fax:606-263-4467
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171280101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health