Provider Demographics
NPI:1760862643
Name:DEIRO, STACIA (PSYD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:DEIRO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 E BROADWAY STE 202
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-1503
Mailing Address - Country:US
Mailing Address - Phone:562-285-6776
Mailing Address - Fax:
Practice Address - Street 1:4105 E BROADWAY STE 202
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-1503
Practice Address - Country:US
Practice Address - Phone:562-285-6776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT113415106H00000X, 106H00000X
CA34836103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist