1104982198 NPI number — DR. DEBRA STACKMAN PHD

Table of content: DR. DEBRA STACKMAN PHD (NPI 1104982198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104982198 NPI number — DR. DEBRA STACKMAN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACKMAN
Provider First Name:
DEBRA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104982198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
VAPAHCS, 3801 MIRANDA AVENUE
Provider Second Line Business Mailing Address:
(116B)
Provider Business Mailing Address City Name:
PALO ALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-493-5000
Provider Business Mailing Address Fax Number:
650-858-3948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 MIRANDA AVENUE
Provider Second Line Business Practice Location Address:
VAPAHCS 116B
Provider Business Practice Location Address City Name:
PALO ALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-493-5000
Provider Business Practice Location Address Fax Number:
650-858-3948
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY15827 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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