MEDICARE: DR. FARREN A STACKHOUSE PH.D., LCMHC, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	15443	NC
2	101YP2500X	Professional Counselor	LPC009419	GA

General Provider Information

NPI Number	:	1215508536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FARREN A STACKHOUSE PH.D., LCMHC, LPC

Provider Business Mailing Address
First Line	:	521 N LIBERTY ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27101-2949
Country	:	US
Telephone Number	:	912-223-2480
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 N LIBERTY ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27101-2949
Country	:	US
Telephone Number	:	912-223-2480
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2021
Last Update Date	:	07/29/2021

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