Provider Demographics
NPI:1164160099
Name:UNSTUCK SPACE PLLC
Entity Type:Organization
Organization Name:UNSTUCK SPACE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:STUCKLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-915-4622
Mailing Address - Street 1:9117 SAGEWOOD DR APT 3108
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-2298
Mailing Address - Country:US
Mailing Address - Phone:817-915-4622
Mailing Address - Fax:
Practice Address - Street 1:1835 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6501
Practice Address - Country:US
Practice Address - Phone:651-583-4447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty