Provider Demographics
NPI:1164996468
Name:STACY, STEPHANIE ELIZABETH
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:STACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ELIZABETH
Other - Last Name:BACHTELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1810 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5108
Mailing Address - Country:US
Mailing Address - Phone:714-425-1605
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST BLDG 23
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist