Provider Demographics
NPI:1598436701
Name:IPPOLITO, STACY (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:IPPOLITO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2502
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2502
Mailing Address - Country:US
Mailing Address - Phone:559-348-3630
Mailing Address - Fax:
Practice Address - Street 1:8711 VAN HORN ST
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3219
Practice Address - Country:US
Practice Address - Phone:559-348-3630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115839106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist