Provider Demographics
NPI:1639349541
Name:KOUTRAKOS, STACY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:KOUTRAKOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:KOUTRAKOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 4353
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-4353
Mailing Address - Country:US
Mailing Address - Phone:602-741-1545
Mailing Address - Fax:
Practice Address - Street 1:1817 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2133
Practice Address - Country:US
Practice Address - Phone:602-741-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3904103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist