Provider Demographics
NPI:1578114690
Name:COVELESKI, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:COVELESKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8450 W CHARLESTON BLVD
Mailing Address - Street 2:2012
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117
Mailing Address - Country:US
Mailing Address - Phone:734-395-0910
Mailing Address - Fax:
Practice Address - Street 1:701 SOUTHHAMPTON ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510
Practice Address - Country:US
Practice Address - Phone:734-395-0910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist