Provider Demographics
NPI:1225474349
Name:STACY M WADLINGTON PH.D.LISCENSE PSYCHOLOGIST P.C.
Entity Type:Organization
Organization Name:STACY M WADLINGTON PH.D.LISCENSE PSYCHOLOGIST P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:WADLINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:323-497-2557
Mailing Address - Street 1:595 E COLORADO BLVD
Mailing Address - Street 2:SUITE 529
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 E COLORADO BLVD
Practice Address - Street 2:SUITE 529
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2039
Practice Address - Country:US
Practice Address - Phone:323-692-7775
Practice Address - Fax:626-793-7553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20509251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health