Provider Demographics
NPI:1669827440
Name:GARDEA, STACY ELIZABETH (CDPT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ELIZABETH
Last Name:GARDEA
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23328 ROBIN HOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-5115
Mailing Address - Country:US
Mailing Address - Phone:425-268-8856
Mailing Address - Fax:
Practice Address - Street 1:23328 ROBIN HOOD DR
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-5115
Practice Address - Country:US
Practice Address - Phone:425-268-8856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WACO60521553101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program