Provider Demographics
NPI:1235675679
Name:AMBRIZ, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:AMBRIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 S SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7040
Mailing Address - Country:US
Mailing Address - Phone:909-332-8498
Mailing Address - Fax:
Practice Address - Street 1:1274 CENTER COURT DR STE 211
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3668
Practice Address - Country:US
Practice Address - Phone:626-339-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician