Provider Demographics
NPI:1386920163
Name:STACKENS, KRISTI
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:STACKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 FLORENCE RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-3484
Mailing Address - Country:US
Mailing Address - Phone:731-727-8012
Mailing Address - Fax:731-727-8013
Practice Address - Street 1:985 FLORENCE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-3484
Practice Address - Country:US
Practice Address - Phone:731-727-8012
Practice Address - Fax:731-727-8013
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health