Provider Demographics
NPI:1104590009
Name:STANBACK, HECTOR LEWIS JR
Entity type:Individual
Prefix:
First Name:HECTOR
Middle Name:LEWIS
Last Name:STANBACK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1452 KNIGHTS TRL
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-6200
Mailing Address - Country:US
Mailing Address - Phone:678-789-4812
Mailing Address - Fax:
Practice Address - Street 1:1452 KNIGHTS TRL
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-6200
Practice Address - Country:US
Practice Address - Phone:678-789-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057756024106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician