Healthcare Provider Details

I. General information

NPI: 1356747620
Provider Name (Legal Business Name): CHRISTINA STACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 SAW MILL CT
SARATOGA SPRINGS NY
12866-5696
US

IV. Provider business mailing address

PO BOX 7955
PORTLAND ME
04112-7955
US

V. Phone/Fax

Practice location:
  • Phone: 518-573-1554
  • Fax:
Mailing address:
  • Phone: 781-629-9713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: