Provider Demographics
NPI:1023361102
Name:WASHINGTON, STACIE R (MFTT)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:R
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:MFTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 LONG BEACH BLVD
Mailing Address - Street 2:228
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2617
Mailing Address - Country:US
Mailing Address - Phone:562-426-3300
Mailing Address - Fax:562-637-3143
Practice Address - Street 1:4000 LONG BEACH BLVD
Practice Address - Street 2:228
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2617
Practice Address - Country:US
Practice Address - Phone:562-426-3300
Practice Address - Fax:562-637-3143
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7205OtherDRUG MEDI-CAL