Provider Demographics
NPI:1578766390
Name:VERNICK, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:VERNICK
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 1:625 CANTRILL DRIVE
Mailing Address - Street 2:APT 435
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-7751
Mailing Address - Country:US
Mailing Address - Phone:530-902-5229
Mailing Address - Fax:
Practice Address - Street 1:584 KENTUCKY AVENUE
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2779
Practice Address - Country:US
Practice Address - Phone:530-661-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health