Provider Demographics
NPI:1407359326
Name:SIMMONS, STACEY (MA, PHD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33300 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91390-2704
Mailing Address - Country:US
Mailing Address - Phone:225-302-0641
Mailing Address - Fax:
Practice Address - Street 1:2211 W MAGNOLIA BLVD # 145
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1753
Practice Address - Country:US
Practice Address - Phone:310-853-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110847106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407359326Medicaid