Provider Demographics
NPI:1669746244
Name:NOLAN-STACK, ELIZABETH JEAN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JEAN
Last Name:NOLAN-STACK
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 1:205 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1406
Mailing Address - Country:US
Mailing Address - Phone:781-761-5077
Mailing Address - Fax:
Practice Address - Street 1:205 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1406
Practice Address - Country:US
Practice Address - Phone:781-761-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18633OtherBCBS
MA1303287OtherMBHP
MA1303287Medicaid
MA99618201OtherNETWORK HEALTH
MA042611055OtherTAXID
MA1004745OtherNHP
MA0000023532OtherBMC
MA1303287Medicaid