Provider Demographics
NPI:1669029559
Name:CERVANTES, STACELYN NICOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:STACELYN
Middle Name:NICOLE
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:STACELYN
Other - Middle Name:NICOLE
Other - Last Name:PECKINPAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 4861
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-1861
Mailing Address - Country:US
Mailing Address - Phone:562-774-2114
Mailing Address - Fax:
Practice Address - Street 1:555 E OCEAN BLVD STE 330
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-5052
Practice Address - Country:US
Practice Address - Phone:562-774-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-24
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106683106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist