Provider Demographics
NPI:1306954557
Name:STACK, VIRGINIA M (MS; LCPC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:M
Last Name:STACK
Suffix:
Gender:F
Credentials:MS; LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:290 SHADY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-2043
Mailing Address - Country:US
Mailing Address - Phone:630-841-8705
Mailing Address - Fax:630-820-5848
Practice Address - Street 1:1121 WARREN AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3570
Practice Address - Country:US
Practice Address - Phone:630-841-8705
Practice Address - Fax:630-820-5848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003337101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health