Provider Demographics
NPI:1962047548
Name:MCQUEEN, STACYE ELIZABETH
Entity type:Individual
Prefix:
First Name:STACYE
Middle Name:ELIZABETH
Last Name:MCQUEEN
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:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-0158
Mailing Address - Country:US
Mailing Address - Phone:606-792-1381
Mailing Address - Fax:
Practice Address - Street 1:104 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224-8928
Practice Address - Country:US
Practice Address - Phone:606-298-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY139343103TC0700X
KY252812101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical