Provider Demographics
NPI:1821205154
Name:STAHNKE, MARK M (MDIV)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:M
Last Name:STAHNKE
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19183 PLOW CREEK RD UNIT 6
Mailing Address - Street 2:
Mailing Address - City:TISKILWA
Mailing Address - State:IL
Mailing Address - Zip Code:61368-9126
Mailing Address - Country:US
Mailing Address - Phone:815-646-4851
Mailing Address - Fax:815-223-4550
Practice Address - Street 1:542 CROSAT ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-2226
Practice Address - Country:US
Practice Address - Phone:815-223-4007
Practice Address - Fax:815-224-4550
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist