Provider Demographics
NPI:1144076555
Name:STACK, ASHLEY TAYLOR
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:TAYLOR
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 HUNTERS CHASE DR APT 504
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-8035
Mailing Address - Country:US
Mailing Address - Phone:757-701-5290
Mailing Address - Fax:
Practice Address - Street 1:2076 S INDEPENDENCE BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-4773
Practice Address - Country:US
Practice Address - Phone:757-622-7272
Practice Address - Fax:757-271-0618
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician