Provider Demographics
NPI:1659992394
Name:LYNCH, STACEY LYNN (LCSW 118950)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:LYNCH
Suffix:
Gender:F
Credentials:LCSW 118950
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1697
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-1697
Mailing Address - Country:US
Mailing Address - Phone:209-617-2662
Mailing Address - Fax:
Practice Address - Street 1:5078 BULLION ST STE 2
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-2416
Practice Address - Country:US
Practice Address - Phone:209-617-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1189501041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical