Provider Demographics
NPI:1346428224
Name:NAKAMURA, STACY W
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:W
Last Name:NAKAMURA
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:PO BOX 8021
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92812-0021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3711 LONG BEACH BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3315
Practice Address - Country:US
Practice Address - Phone:562-216-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27111101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health