Provider Demographics
NPI:1407062383
Name:STACK, PATRICK CHARLES (DMIN)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:CHARLES
Last Name:STACK
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 VILLAWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-4916
Mailing Address - Country:US
Mailing Address - Phone:314-963-1962
Mailing Address - Fax:314-968-7126
Practice Address - Street 1:10702 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-1321
Practice Address - Country:US
Practice Address - Phone:314-966-1022
Practice Address - Fax:314-968-7126
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2775101YA0400X
MO000122101YP2500X
MO300107106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist