Provider Demographics
NPI:1083835599
Name:STACKHOUSE, LISA ADAMS (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ADAMS
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 S. LENOLA RD
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057
Mailing Address - Country:US
Mailing Address - Phone:856-439-9300
Mailing Address - Fax:856-439-1190
Practice Address - Street 1:509 S. LENOLA RD
Practice Address - Street 2:SUITE 4A
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057
Practice Address - Country:US
Practice Address - Phone:856-439-9300
Practice Address - Fax:856-439-1190
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB040991002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJST565146Medicare ID - Type Unspecified
NJC58907Medicare UPIN