MEDICARE: MS. BRENDA LEE STACK LMHC, CAP, NCC

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	101YM0800X	Mental Health Counselor	MH5982	FL

General Provider Information

NPI Number	:	1689725913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRENDA LEE STACK LMHC, CAP, NCC

Provider Business Mailing Address
First Line	:	PO BOX 321
Second Line	:
City	:	MIMS
State	:	FL
Zip	:	32754-0321
Country	:	US
Telephone Number	:	321-268-8828
Fax Number	:	321-567-0888

Provider Business Practice Location Address
First Line	:	3302 GREEN ST
Second Line	:
City	:	MIMS
State	:	FL
Zip	:	32754-3813
Country	:	US
Telephone Number	:	321-268-8828
Fax Number	:	321-567-0888

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

Provider Enumeration Date	:	01/15/2007
Last Update Date	:	07/12/2008

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