Provider Demographics
NPI:1679155030
Name:STACKHOUSE, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:STACKHOUSE
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 1:3614 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE BEACH
Mailing Address - State:MD
Mailing Address - Zip Code:20732-3130
Mailing Address - Country:US
Mailing Address - Phone:240-523-3497
Mailing Address - Fax:
Practice Address - Street 1:3614 11TH ST
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE BEACH
Practice Address - State:MD
Practice Address - Zip Code:20732-3130
Practice Address - Country:US
Practice Address - Phone:240-523-3497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA0538103T00000X
MD36187103TS0200X
MDLGP13404101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty