Provider Demographics
NPI:1821458225
Name:STACKS, MANDY LEIGH (LPC, ADC)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:LEIGH
Last Name:STACKS
Suffix:
Gender:F
Credentials:LPC, ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SAINT CATHERINES CT
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-9055
Mailing Address - Country:US
Mailing Address - Phone:803-577-0265
Mailing Address - Fax:
Practice Address - Street 1:320 MIDLAND PKWY STE C
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-7195
Practice Address - Country:US
Practice Address - Phone:803-577-0265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YA0400X
SC9989101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAD08LAMedicaid