Provider Demographics
NPI:1316403892
Name:STACK, BRENDAN (LPC, LADC)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:STACK
Suffix:
Gender:
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 WATERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1502
Mailing Address - Country:US
Mailing Address - Phone:518-610-4528
Mailing Address - Fax:
Practice Address - Street 1:519 HERITAGE RD STE 2A5
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-6694
Practice Address - Country:US
Practice Address - Phone:518-610-4528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001323101YA0400X
CT4530101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty