Provider Demographics
NPI:1982898177
Name:KOEKKOEK, STACEY (MS RD, LDN, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:KOEKKOEK
Suffix:
Gender:F
Credentials:MS RD, LDN, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 BOSTON POST RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-1889
Mailing Address - Country:US
Mailing Address - Phone:508-276-1743
Mailing Address - Fax:
Practice Address - Street 1:260 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-1889
Practice Address - Country:US
Practice Address - Phone:508-276-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2606133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered