Provider Demographics
NPI:1346654282
Name:STAGG, BRIAN LEE (EDS)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LEE
Last Name:STAGG
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4126 S DEMAREE ST STE B
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-9514
Mailing Address - Country:US
Mailing Address - Phone:559-943-7076
Mailing Address - Fax:
Practice Address - Street 1:4126 S DEMAREE ST STE B
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-9514
Practice Address - Country:US
Practice Address - Phone:559-943-7076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-8934103K00000X
CA3487103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst