Provider Demographics
NPI:1114499811
Name:STACK, KELLAN JACE (LCSW)
Entity type:Individual
Prefix:MR
First Name:KELLAN
Middle Name:JACE
Last Name:STACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ALYCIA
Other - Middle Name:ANN
Other - Last Name:STACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2441 SHOOTING STAR WAY
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-9243
Mailing Address - Country:US
Mailing Address - Phone:970-689-6388
Mailing Address - Fax:
Practice Address - Street 1:2441 SHOOTING STAR WAY
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-9243
Practice Address - Country:US
Practice Address - Phone:970-689-6388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099302781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical