Provider Demographics
NPI:1437801230
Name:MACKAMAN, STACEY (AMFT)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:MACKAMAN
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:170 ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-5229
Mailing Address - Country:US
Mailing Address - Phone:312-758-2428
Mailing Address - Fax:
Practice Address - Street 1:170 ARDMORE AVE
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-5229
Practice Address - Country:US
Practice Address - Phone:312-758-2428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130390106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist