Provider Demographics
NPI:1790560043
Name:CATANZARITE, STACY LIANE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LIANE
Last Name:CATANZARITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LIANE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0510
Mailing Address - Country:US
Mailing Address - Phone:209-523-4573
Mailing Address - Fax:
Practice Address - Street 1:100 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0510
Practice Address - Country:US
Practice Address - Phone:209-523-4573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAMPSS-ICWOFK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator