Provider Demographics
NPI:1316364375
Name:STACEY KOEKKOEK
Entity Type:Organization
Organization Name:STACEY KOEKKOEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST/DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEKKOEK
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD, LDN, LMHC
Authorized Official - Phone:508-276-1743
Mailing Address - Street 1:260 BOSTON POST RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-1889
Mailing Address - Country:US
Mailing Address - Phone:508-276-1743
Mailing Address - Fax:
Practice Address - Street 1:260 BOSTON POST RD
Practice Address - Street 2:SUITE 11
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-1889
Practice Address - Country:US
Practice Address - Phone:508-276-1743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty