Provider Demographics
NPI:1679088132
Name:STACEY HOUK FAMILY ENRICHMENT CENTER LLC
Entity Type:Organization
Organization Name:STACEY HOUK FAMILY ENRICHMENT CENTER LLC
Other - Org Name:STACEY HOUK LEARNING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:STERNITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-338-2256
Mailing Address - Street 1:1757 W C ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-3215
Mailing Address - Country:US
Mailing Address - Phone:307-338-2256
Mailing Address - Fax:
Practice Address - Street 1:1765 W C ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240
Practice Address - Country:US
Practice Address - Phone:307-338-2256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty