Provider Demographics
NPI:1457243164
Name:STACK, MEGHAN MARIE SMITH (EDS, NCSP)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:MARIE SMITH
Last Name:STACK
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-4101
Mailing Address - Country:US
Mailing Address - Phone:402-727-3084
Mailing Address - Fax:
Practice Address - Street 1:130 E 9TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-4101
Practice Address - Country:US
Practice Address - Phone:402-727-3084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20220003753103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty