Provider Demographics
NPI:1649678152
Name:STUCK, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:STUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1787
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0261
Mailing Address - Country:US
Mailing Address - Phone:541-500-8655
Mailing Address - Fax:800-433-1396
Practice Address - Street 1:1040 CRATER LAKE AVE STE D
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6295
Practice Address - Country:US
Practice Address - Phone:541-500-8655
Practice Address - Fax:800-433-1396
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4877101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health