Provider Demographics
NPI:1750446720
Name:STAGNO, M
Entity type:Individual
Prefix:
First Name:M
Middle Name:
Last Name:STAGNO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 E SCHAUMBURG RD
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194-5166
Mailing Address - Country:US
Mailing Address - Phone:847-895-4540
Mailing Address - Fax:
Practice Address - Street 1:1375 E SCHAUMBURG RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-5166
Practice Address - Country:US
Practice Address - Phone:847-895-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005066103TF0200X, 103TH0100X, 103TC0700X
IL071005066103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1607281OtherBLUE CROSS & BLUE SHIELD
IL1607281OtherBLUE CROSS & BLUE SHIELD