Provider Demographics
NPI:1881197366
Name:MOLINA, STACEY MARJEAN (BCBA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARJEAN
Last Name:MOLINA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 GRAND CANAL BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8107
Mailing Address - Country:US
Mailing Address - Phone:209-345-1848
Mailing Address - Fax:
Practice Address - Street 1:1115 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1003
Practice Address - Country:US
Practice Address - Phone:209-572-2589
Practice Address - Fax:209-572-1461
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18-49821106S00000X
106S00000X
CA1-22-57600103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician