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General NPI Number Information
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NPI Number | 1316403892
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Entity Type | Individual
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Provider Name | BRENDAN STACK LPC, LADC
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Gender | Male
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Dates
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Enumeration Date | 02/20/2019
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Last Update Date | 07/18/2025
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Provider Practice Location Address
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Address Line | 519 HERITAGE RD STE 2A5
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City | SOUTHBURY
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State | CT
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Zip | 06488-6694
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Country | US
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Telephone | 518-610-4528
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Fax |
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Provider Business Mailing Address
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Address Line | 127 WATERTOWN RD
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City | MIDDLEBURY
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State | CT
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Zip | 06762-1502
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Country | US
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Telephone | 518-610-4528
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 001323
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4530
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License Number State | CT
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