Healthcare Provider Details

I. General information

NPI: 1518536432
Provider Name (Legal Business Name): DARRA LYNN STACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 NAUTILUS DR
MANAHAWKIN NJ
08050-2448
US

IV. Provider business mailing address

65 OXYCOCUS RD
MANAHAWKIN NJ
08050-2939
US

V. Phone/Fax

Practice location:
  • Phone: 732-966-4166
  • Fax:
Mailing address:
  • Phone: 609-548-8841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL06415500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15169130
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerCAQH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: