Provider Demographics
NPI:1861807323
Name:WHITE, STACY (LAC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E 5TH ST
Mailing Address - Street 2:PO BOX 711
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-2206
Mailing Address - Country:US
Mailing Address - Phone:316-283-6743
Mailing Address - Fax:316-283-6830
Practice Address - Street 1:3820 N TOBEN ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2903
Practice Address - Country:US
Practice Address - Phone:316-634-3954
Practice Address - Fax:316-634-3956
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100106710 LMedicaid