Provider Demographics
NPI:1932480415
Name:STACK, CHRISTOPHER L (MA/DOCTORAL STUDEN)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:L
Last Name:STACK
Suffix:
Gender:M
Credentials:MA/DOCTORAL STUDEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5693 BLUE GRASS DR
Mailing Address - Street 2:
Mailing Address - City:WALBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43465-1148
Mailing Address - Country:US
Mailing Address - Phone:419-838-7626
Mailing Address - Fax:
Practice Address - Street 1:5693 BLUE GRASS DR
Practice Address - Street 2:
Practice Address - City:WALBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43465-1148
Practice Address - Country:US
Practice Address - Phone:419-838-7626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0700856101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health