Provider Demographics
NPI:1164242590
Name:VAN ECK, STACEY (MED, EDS)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:VAN ECK
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3829 FOX CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9150
Mailing Address - Country:US
Mailing Address - Phone:269-718-9198
Mailing Address - Fax:
Practice Address - Street 1:2720 CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1220
Practice Address - Country:US
Practice Address - Phone:574-262-5542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool