Doctor Name: | MS. BRENDA LEE STACK |
NPI Number: | 1689725913 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LMHC, CAP, NCC |
License Number: | MH5982 |
Business Practice Address: | 3302 Green St Mims, FL - 327543813 |
Business Phone Number: | 3212688828 |
Business Fax Number: | 3215670888 |
Mailing Address: | Po Box 321, MIMS |
State: | FL |
Postal Code: | 327540321 |
Phone Number: | 3212688828 |
Fax Number: | 3215670888 |
NPI Enumeration Date: | 01/15/2007 |
NPI Last Update Date: | 07/12/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | MH5982 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | FL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |