Provider Demographics
NPI:1053669911
Name:STACK, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14841 U PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2527
Mailing Address - Country:US
Mailing Address - Phone:402-609-0192
Mailing Address - Fax:
Practice Address - Street 1:14841 U PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2527
Practice Address - Country:US
Practice Address - Phone:402-609-0192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor