Provider Demographics
NPI:1083881742
Name:SMALL, STACY ERIN CLARK (MFT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ERIN CLARK
Last Name:SMALL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-5003
Mailing Address - Country:US
Mailing Address - Phone:916-338-1001
Mailing Address - Fax:916-338-1001
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:279-200-2802
Practice Address - Fax:877-738-4262
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50473106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist