Provider Demographics
NPI:1326382615
Name:DETWEILER, STACEY BETH (MS, CGC)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:BETH
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:BETH
Other - Last Name:RICKARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:2350 W. EL CAMINO REAL
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2603
Practice Address - Country:US
Practice Address - Phone:650-596-4230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X
CA16187170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS