Provider Demographics
NPI:1982010518
Name:SICKLE, STACIA
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:SICKLE
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 1:1533 VIA LA SILVA
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-9209
Mailing Address - Country:US
Mailing Address - Phone:805-388-8089
Mailing Address - Fax:
Practice Address - Street 1:1100 FLYNN RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8737
Practice Address - Country:US
Practice Address - Phone:805-760-0533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALC15737101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health