Provider Demographics
NPI:1952671950
Name:STACK, MICHELLE ELENA (PHD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELENA
Last Name:STACK
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 402 BOX 1786
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-1018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DR. HITZELBERGER STRASSE
Practice Address - Street 2:
Practice Address - City:LANDSTUHL
Practice Address - State:RHEILAND-PFALZ
Practice Address - Zip Code:66849
Practice Address - Country:DE
Practice Address - Phone:314-590-5059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11585103T00000X, 103TB0200X, 103TC0700X, 103TR0400X, 103G00000X
NM1195103TB0200X, 103TC0700X, 103TH0004X, 103TR0400X
CT3230103TC0700X, 103TR0400X
FL11585103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth