Provider Demographics
NPI:1962500553
Name:THACKER, STACEY B (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:B
Last Name:THACKER
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 1:1879 E FIR AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720
Mailing Address - Country:US
Mailing Address - Phone:559-323-8484
Mailing Address - Fax:559-323-8686
Practice Address - Street 1:1879 E FIR AVE
Practice Address - Street 2:STE 103 ROUBICEK & SHAW COUNSELING
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-323-8484
Practice Address - Fax:559-323-8686
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT43024106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist