Provider Demographics
NPI:1619101227
Name:STACK, AMY MARIE (LPC)
Entity Type:Individual
Prefix:MISS
First Name:AMY
Middle Name:MARIE
Last Name:STACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-2169
Mailing Address - Country:US
Mailing Address - Phone:203-597-1935
Mailing Address - Fax:203-597-8711
Practice Address - Street 1:70 PINE ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-2169
Practice Address - Country:US
Practice Address - Phone:203-597-1935
Practice Address - Fax:203-597-8711
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001599101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health