Provider Demographics
NPI:1215508536
Name:STACKHOUSE, FARREN A (PHD, LCMHC, LPC)
Entity type:Individual
Prefix:DR
First Name:FARREN
Middle Name:A
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:PHD, LCMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2949
Mailing Address - Country:US
Mailing Address - Phone:912-223-2480
Mailing Address - Fax:
Practice Address - Street 1:521 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2949
Practice Address - Country:US
Practice Address - Phone:912-223-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15443101YP2500X
GALPC009419101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional