Provider Demographics
NPI:1255109260
Name:LJEPAVA, STACI LYNN (MSW, PPSC)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:LYNN
Last Name:LJEPAVA
Suffix:
Gender:F
Credentials:MSW, PPSC
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:LYNN
Other - Last Name:SHRADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW PPSC
Mailing Address - Street 1:24569 HUTCHINSON RD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95033-8554
Mailing Address - Country:US
Mailing Address - Phone:408-513-4917
Mailing Address - Fax:
Practice Address - Street 1:850 N 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6317
Practice Address - Country:US
Practice Address - Phone:408-535-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2100388101041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool