Provider Demographics
NPI:1417493347
Name:STAKEY, KATHRYN L (BS)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:L
Last Name:STAKEY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BRET DR
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-2506
Mailing Address - Country:US
Mailing Address - Phone:860-302-4420
Mailing Address - Fax:
Practice Address - Street 1:144 MAIN ST STE G
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-3239
Practice Address - Country:US
Practice Address - Phone:860-302-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106S00000X
CT1041103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty