Provider Demographics
NPI:1982421723
Name:THACKER-MAYHORN, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:THACKER-MAYHORN
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 1:1199 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-9476
Mailing Address - Country:US
Mailing Address - Phone:304-687-5119
Mailing Address - Fax:
Practice Address - Street 1:1199 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9476
Practice Address - Country:US
Practice Address - Phone:304-687-5119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency