Provider Demographics
NPI:1023370350
Name:BAUM, STACIE A
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:A
Last Name:BAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:STACIE
Other - Middle Name:A
Other - Last Name:ATKINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4545 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-0946
Mailing Address - Country:US
Mailing Address - Phone:559-229-3561
Mailing Address - Fax:
Practice Address - Street 1:4545 N WEST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705
Practice Address - Country:US
Practice Address - Phone:559-229-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT106217106H00000X
CAIMF67387106H00000X
CA145931106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist