Provider Demographics
NPI:1518908680
Name:GOODMAN EATON, STACEY A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:A
Last Name:GOODMAN EATON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:12520 HIGH BLUFF DR
Mailing Address - Street 2:STE 135
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3066
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:12520 HIGH BLUFF DR
Practice Address - Street 2:STE 135
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3066
Practice Address - Country:US
Practice Address - Phone:619-383-6700
Practice Address - Fax:619-383-6701
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS189131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN
CASW18913Medicare PIN