Provider Demographics
NPI:1104982198
Name:STACKMAN, DEBRA (PHD)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:
Last Name:STACKMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VAPAHCS, 3801 MIRANDA AVENUE
Mailing Address - Street 2:(116B)
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304
Mailing Address - Country:US
Mailing Address - Phone:650-493-5000
Mailing Address - Fax:650-858-3948
Practice Address - Street 1:3801 MIRANDA AVENUE
Practice Address - Street 2:VAPAHCS 116B
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:650-858-3948
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15827103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY15827Medicare UPIN