Provider Demographics
NPI:1932300878
Name:MIAO, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MIAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 SPAANS DR STE F
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-8609
Mailing Address - Country:US
Mailing Address - Phone:209-744-9909
Mailing Address - Fax:209-744-9910
Practice Address - Street 1:750 SPAANS DR STE F
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-8609
Practice Address - Country:US
Practice Address - Phone:209-744-9909
Practice Address - Fax:209-744-9910
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
CASUDCC10476101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health