Provider Demographics
NPI:1952671950
Name:STACK, MICHELLE ELENA (PHD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELENA
Last Name:STACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-9116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-9116
Practice Address - Country:US
Practice Address - Phone:941-363-0878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3230103G00000X, 103T00000X, 103TB0200X, 103TC0700X, 103TR0400X
NM1195103G00000X, 103T00000X, 103TB0200X, 103TC0700X, 103TH0004X, 103TR0400X
FL11585103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation