Provider Demographics
NPI:1316537988
Name:KUNTZ, STACEY ELLA
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ELLA
Last Name:KUNTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ELLA
Other - Last Name:KUNTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:T-LMHC
Mailing Address - Street 1:848 RAM TRL SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3565
Mailing Address - Country:US
Mailing Address - Phone:505-357-7381
Mailing Address - Fax:
Practice Address - Street 1:848 RAM TRL SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-3565
Practice Address - Country:US
Practice Address - Phone:505-357-7381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0215021101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health