Doctor Name: | DR. SHIRLEY L. STACK |
NPI Number: | 1366695447 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PH.D. |
License Number: | PSY14640 |
Business Practice Address: | 170 Village Crest Avila Beach, CA - 934242442 |
Business Phone Number: | 8055957936 |
Business Fax Number: | |
Mailing Address: | Po Box 2442, AVILA BEACH |
State: | CA |
Postal Code: | 934242442 |
Phone Number: | 8055957936 |
Fax Number: | |
NPI Enumeration Date: | 11/03/2008 |
NPI Last Update Date: | 11/03/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | PSY14640 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CA |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |