Provider Demographics
NPI:1922757848
Name:ACKERLIND, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ACKERLIND
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 1:1537 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5315
Mailing Address - Country:US
Mailing Address - Phone:801-556-5762
Mailing Address - Fax:
Practice Address - Street 1:1537 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-5315
Practice Address - Country:US
Practice Address - Phone:801-556-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5559994-2501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling