Provider Demographics
NPI:1023195864
Name:STACK, DEBORAH JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:JEAN
Last Name:STACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 PROSPECT AVENUE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-258-6065
Mailing Address - Fax:860-232-5077
Practice Address - Street 1:682 PROSPECT AVENUE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105
Practice Address - Country:US
Practice Address - Phone:860-258-6065
Practice Address - Fax:860-232-5077
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1238103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060001238CT01OtherBCBS
CTHAS394OtherOXFORD