Basic Information
| Provider Information | |||||||||
| NPI: | 1043685712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACK | ||||||||
| FirstName: | COURTNEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1812 E HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532074000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084396893 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 W CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532121123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147276320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2015 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101Y00000X | 6859-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.