Healthcare Provider Details

I. General information

NPI: 1043685712
Provider Name (Legal Business Name): COURTNEY STACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W CAPITOL DR
MILWAUKEE WI
53212-1123
US

IV. Provider business mailing address

1812 E HOWARD AVE
MILWAUKEE WI
53207-4000
US

V. Phone/Fax

Practice location:
  • Phone: 414-727-6320
  • Fax:
Mailing address:
  • Phone: 708-439-6893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6859-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: