Provider Demographics
NPI:1619008455
Name:HART, STACY MARIE (IMF #59027)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:HART
Suffix:
Gender:F
Credentials:IMF #59027
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 CHANATE ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404
Mailing Address - Country:US
Mailing Address - Phone:707-565-5002
Mailing Address - Fax:707-565-4814
Practice Address - Street 1:3333 CHANATE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1707
Practice Address - Country:US
Practice Address - Phone:707-565-5002
Practice Address - Fax:707-565-4814
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59027106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist