Provider Demographics
NPI:1487301404
Name:STAM, KATHERINE MELISSA (LMSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MELISSA
Last Name:STAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 SIKES DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:KEMPNER
Mailing Address - State:TX
Mailing Address - Zip Code:76539-6928
Mailing Address - Country:US
Mailing Address - Phone:919-720-1101
Mailing Address - Fax:
Practice Address - Street 1:1216 DUNCAN RD
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-7409
Practice Address - Country:US
Practice Address - Phone:254-577-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1066761041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical