Provider Demographics
NPI:1922122340
Name:NUSSBAUM, STACEY LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:710 LAWRENCE EXPY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:408-992-4800
Mailing Address - Fax:
Practice Address - Street 1:231 GRANT AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-1907
Practice Address - Country:US
Practice Address - Phone:650-321-5545
Practice Address - Fax:650-321-5232
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 217311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q09659Medicare UPIN
ZZZ28469ZMedicare ID - Type Unspecified