Provider Demographics
NPI:1205964814
Name:MCCALL-MARTIN, STACY ANDREA (MFT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANDREA
Last Name:MCCALL-MARTIN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 IMPERIAL HWY STE 400
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-1419
Mailing Address - Country:US
Mailing Address - Phone:562-807-6100
Mailing Address - Fax:
Practice Address - Street 1:12501 IMPERIAL HWY STE 400
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-1419
Practice Address - Country:US
Practice Address - Phone:562-807-6143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid