Provider Demographics
NPI:1447397641
Name:ROSS, STACI DAVORA (LMFT)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:DAVORA
Last Name:ROSS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16712 DOG CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LAKEHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:96051-9501
Mailing Address - Country:US
Mailing Address - Phone:530-917-0121
Mailing Address - Fax:
Practice Address - Street 1:1352 OREGON ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1621
Practice Address - Country:US
Practice Address - Phone:530-917-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 46679106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist