Healthcare Provider Details

I. General information

NPI: 1316820285
Provider Name (Legal Business Name): MEGAN STASIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 SUDDERTH DR
RUIDOSO NM
88345-6119
US

IV. Provider business mailing address

UNIT 7600 BOX 267
DPO AE
09710-0267
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-2368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number402668
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: