Provider Demographics
NPI:1053915520
Name:STOCKHAM, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:STOCKHAM
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 1:13850 COUNTY ROAD D
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-9409
Mailing Address - Country:US
Mailing Address - Phone:567-454-0340
Mailing Address - Fax:
Practice Address - Street 1:13850 COUNTY ROAD D
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-9409
Practice Address - Country:US
Practice Address - Phone:567-454-0340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YP2500X, 172A00000X, 373H00000X, 376J00000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist