Provider Demographics
NPI:1639296601
Name:STAVN, MARY J
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:STAVN
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 1:2415 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1164
Mailing Address - Country:US
Mailing Address - Phone:650-363-4030
Mailing Address - Fax:650-328-6834
Practice Address - Street 1:2415 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:EAST PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-1164
Practice Address - Country:US
Practice Address - Phone:650-363-4030
Practice Address - Fax:650-328-6834
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW17637104100000X
CALCS 261451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker