Healthcare Provider Details

I. General information

NPI: 1124146121
Provider Name (Legal Business Name): THOMAS STACKHOUSE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 COUNTY ST
NEW BEDFORD MA
02740-5107
US

IV. Provider business mailing address

105 WEBSTER ST STE 8
HANOVER MA
02339-1227
US

V. Phone/Fax

Practice location:
  • Phone: 508-997-0794
  • Fax: 508-999-6607
Mailing address:
  • Phone: 781-754-6545
  • Fax: 508-999-6607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2679
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: