Provider Demographics
NPI:1851419592
Name:ANDERSON YOUNG, STACEY L (LMFT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:ANDERSON YOUNG
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:918 15TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1115
Practice Address - Country:US
Practice Address - Phone:209-727-2646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51993OtherBOARD OF BEHAVIORAL SCIENCES