Provider Demographics
NPI:1316820285
Name:STASIAK, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:STASIAK
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:UNIT 7600 BOX 267
Mailing Address - Street 2:
Mailing Address - City:DPO
Mailing Address - State:AE
Mailing Address - Zip Code:09710-0267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2002 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6119
Practice Address - Country:US
Practice Address - Phone:575-257-2368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM402668103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool