Provider Demographics
NPI:1497200356
Name:CADDEN, STACEY JOANNE
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:JOANNE
Last Name:CADDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:JOANNE
Other - Last Name:CADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:26100 NEWPORT RD
Mailing Address - Street 2:SUITE A 12 #43
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7002
Mailing Address - Country:US
Mailing Address - Phone:951-442-0193
Mailing Address - Fax:951-443-4586
Practice Address - Street 1:3816 GALENA PL
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-7290
Practice Address - Country:US
Practice Address - Phone:951-442-0193
Practice Address - Fax:951-443-4586
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5177225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist