Provider Demographics
NPI:1578891230
Name:ROBERTS, STACY (MSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 EUCLID ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3330
Mailing Address - Country:US
Mailing Address - Phone:801-380-9513
Mailing Address - Fax:
Practice Address - Street 1:1528 EUCLID ST APT 1
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3330
Practice Address - Country:US
Practice Address - Phone:801-380-9513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22312104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker