Provider Demographics
NPI:1164047965
Name:PALACIOS, STEPHANIE (MFT, PSYD CANDIDATE)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PALACIOS
Suffix:
Gender:F
Credentials:MFT, PSYD CANDIDATE
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MOCERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT, PSYD CANDIDATE
Mailing Address - Street 1:1493 CAMBRIDGE ST RM 239
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1099
Mailing Address - Country:US
Mailing Address - Phone:617-665-1183
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST RM 239
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1099
Practice Address - Country:US
Practice Address - Phone:617-665-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TB0200X, 103TH0100X, 106H00000X, 390200000X
ILNA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist