Provider Demographics
NPI:1114635695
Name:NEAL, STACEY WARREN
Entity Type:Individual
Prefix:MR
First Name:STACEY
Middle Name:WARREN
Last Name:NEAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11648 HALTER ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-8116
Mailing Address - Country:US
Mailing Address - Phone:760-956-2462
Mailing Address - Fax:
Practice Address - Street 1:658 E BRIER DR STE 350
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2875
Practice Address - Country:US
Practice Address - Phone:800-398-0018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator