Provider Demographics
NPI:1508271552
Name:STAPLETON, STACY (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:STAPLETON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 ALCATRAZ AVE
Mailing Address - Street 2:APT 8
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1153
Mailing Address - Country:US
Mailing Address - Phone:925-783-1426
Mailing Address - Fax:
Practice Address - Street 1:400 29TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3522
Practice Address - Country:US
Practice Address - Phone:415-748-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-29
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-15980103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-1741898Medicaid