Provider Demographics
NPI:1942407648
Name:THOMPSON, STACEY LYNN (MFT-I, AT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MFT-I, AT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:DEFORREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT, ATR
Mailing Address - Street 1:1346 SETTLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-2363
Mailing Address - Country:US
Mailing Address - Phone:415-606-7756
Mailing Address - Fax:
Practice Address - Street 1:1346 SETTLE AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-2363
Practice Address - Country:US
Practice Address - Phone:415-606-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT78180106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA109453OtherSAN JOSE CITY EMPLOYEE