Provider Demographics
NPI:1629286406
Name:STACKER, CONNETT
Entity Type:Individual
Prefix:MRS
First Name:CONNETT
Middle Name:
Last Name:STACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 BARTH ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-3052
Mailing Address - Country:US
Mailing Address - Phone:810-767-6553
Mailing Address - Fax:
Practice Address - Street 1:3169 W PIERSON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-6805
Practice Address - Country:US
Practice Address - Phone:810-785-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)