Provider Demographics
NPI:1417320185
Name:GEORGE, STACY DONOVAN (MA, LMFT)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:DONOVAN
Last Name:GEORGE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5237 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1414
Mailing Address - Country:US
Mailing Address - Phone:510-496-6012
Mailing Address - Fax:
Practice Address - Street 1:5237 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1414
Practice Address - Country:US
Practice Address - Phone:510-496-6012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86212101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health