Provider Demographics
NPI:1639367139
Name:SELCO, STACEY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:SELCO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6651 BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5529
Mailing Address - Country:US
Mailing Address - Phone:213-694-0045
Mailing Address - Fax:
Practice Address - Street 1:439 W 97TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3968
Practice Address - Country:US
Practice Address - Phone:213-694-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA183331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical