Individual
DR. SHANEEN DIANE STACER
Active
Individual
DR. SHANEEN DIANE STACER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
3079-57
WI
103TA0400X
Addiction (Substance Use Disorder) Psychologist
3079-57
WI
103TB0200X
Cognitive & Behavioral Psychologist
3079-57
WI
103TC0700X
Clinical Psychologist
Primary
2500
OR
103TC0700X
Clinical Psychologist
3079-57
WI
103TC2200X
Clinical Child & Adolescent Psychologist
3079-57
WI
103TH0004X
Health Psychologist
3079-57
WI
103TH0100X
Health Service Psychologist
3079-57
WI
103TP2701X
Group Psychotherapy Psychologist
3079-57
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1407812365
NORTH BEND MEDICAL CENTER GROUP NPI
OR
01
—
161133
NORTH BEND MEDICAL CENTER GROUP MEDICAID
OR
05
—
500684206
—
OR
01
—
R0000WFBTV
NORTH BEND MEDICAL CENTER GROUP MEDICARE
OR
Enumeration date
10/04/2013
Last updated
09/08/2016
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