1306954557 NPI number — VIRGINIA M STACK M.S.; L.C.P.C.

Table of content: VIRGINIA M STACK M.S.; L.C.P.C. (NPI 1306954557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306954557 NPI number — VIRGINIA M STACK M.S.; L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACK
Provider First Name:
VIRGINIA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.; L.C.P.C.
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:
1306954557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 SHADY BROOK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-2043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-841-8705
Provider Business Mailing Address Fax Number:
630-820-5848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 WARREN AVE
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
DOWNERS GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60515-3570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-841-8705
Provider Business Practice Location Address Fax Number:
630-820-5848
Provider Enumeration Date:
08/28/2006

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: 101YM0800X , with the licence number:  180-003337 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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