MEDICARE: MOLLY STACKHOUSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	PC016613	PA
2	103T00000X	Psychologist	A0538	MD
3	103TS0200X	School Psychologist	36187	MD
4	101YM0800X	Mental Health Counselor	LC15842	MD

General Provider Information

NPI Number	:	1679155030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY STACKHOUSE

Provider Business Mailing Address
First Line	:	3614 11TH ST
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-3130
Country	:	US
Telephone Number	:	240-523-3497
Fax Number	:

Provider Business Practice Location Address
First Line	:	3614 11TH ST
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-3130
Country	:	US
Telephone Number	:	240-523-3497
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2021
Last Update Date	:	11/15/2024

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Directions to “ MOLLY STACKHOUSE ” Practice Location

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