Provider Demographics
NPI:1679134944
Name:STACKS, KEYONIA S
Entity type:Individual
Prefix:MS
First Name:KEYONIA
Middle Name:S
Last Name:STACKS
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 1:33 EAGLE ST APT 2J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-6065
Mailing Address - Country:US
Mailing Address - Phone:484-862-2406
Mailing Address - Fax:
Practice Address - Street 1:184 ELDRIDGE ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-2924
Practice Address - Country:US
Practice Address - Phone:212-453-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA29698163103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation