Provider Demographics
NPI:1477857951
Name:CLARKE, STACY-ANN (BHS)
Entity Type:Individual
Prefix:MS
First Name:STACY-ANN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:BHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-525-6146
Mailing Address - Fax:209-525-5361
Practice Address - Street 1:1904 RICHLAND AVE
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-4562
Practice Address - Country:US
Practice Address - Phone:209-525-7411
Practice Address - Fax:209-541-2083
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-27
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247445164X00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No164X00000XNursing Service ProvidersLicensed Vocational Nurse