Provider Demographics
NPI:1811313117
Name:RUCKER, STACY L (LMSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:RUCKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 FAIRMOUNT BOX 109
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67260-0109
Mailing Address - Country:US
Mailing Address - Phone:316-978-5419
Mailing Address - Fax:316-978-5822
Practice Address - Street 1:1845 FAIRMOUNT BOX 109
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67260-0109
Practice Address - Country:US
Practice Address - Phone:316-978-5419
Practice Address - Fax:316-978-5822
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6178104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker