Provider Demographics
NPI:1336388826
Name:STACEY, DESMOND GRAHAM (PHD)
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:GRAHAM
Last Name:STACEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 W OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4927
Mailing Address - Country:US
Mailing Address - Phone:909-798-1814
Mailing Address - Fax:
Practice Address - Street 1:339 CAJON ST STE B
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5983
Practice Address - Country:US
Practice Address - Phone:909-723-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18291103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical