Provider Demographics
NPI:1558156802
Name:STAKUTIS, DANIEL
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:STAKUTIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIVERS EDGE DR UNIT 448
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5477
Mailing Address - Country:US
Mailing Address - Phone:508-380-2208
Mailing Address - Fax:
Practice Address - Street 1:100 RIVERS EDGE DR UNIT 448
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5477
Practice Address - Country:US
Practice Address - Phone:508-380-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2312263363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health