Provider Demographics
NPI:1619528361
Name:ATWATER, STACEY (MA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ATWATER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27936 CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:CA
Mailing Address - Zip Code:91350-1967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25134 RYE CANYON LOOP
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5045
Practice Address - Country:US
Practice Address - Phone:661-843-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst