Provider Demographics
NPI:1700605052
Name:STALTER, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:STALTER
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 1:10485 STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:ROSHOLT
Mailing Address - State:WI
Mailing Address - Zip Code:54473-8871
Mailing Address - Country:US
Mailing Address - Phone:715-321-1093
Mailing Address - Fax:
Practice Address - Street 1:2055 REYKO RD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2828
Practice Address - Country:US
Practice Address - Phone:904-659-7434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health