Provider Demographics
NPI:1902866718
Name:STACK, KATHLEEN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:STACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 JEFFERSON AVE
Mailing Address - Street 2:MCDONALD ARMY HEALTH CENTER
Mailing Address - City:FT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-5548
Mailing Address - Country:US
Mailing Address - Phone:757-344-6921
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:MCDONALD ARMY HEALTH CENTER
Practice Address - City:FT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-5548
Practice Address - Country:US
Practice Address - Phone:757-344-6921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010442952084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry