Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | 29698163 | PA |
NPI | 1679134944 |
---|---|
Provider Name | Ms. Keyonia S Stacks |
First Address | Brooklyn, NY 11222-6065 |
Second Address | New York, NY 10002-2924 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2019 |
Last Update Date | 26/06/2019 |