Provider Demographics
NPI:1457769507
Name:HALL, STACY LYNN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:HALL
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 1:34111 WILDWOOD CANYON RD
Mailing Address - Street 2:#70
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2644
Mailing Address - Country:US
Mailing Address - Phone:909-553-2244
Mailing Address - Fax:
Practice Address - Street 1:34111 WILDWOOD CANYON RD
Practice Address - Street 2:#70
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2644
Practice Address - Country:US
Practice Address - Phone:909-553-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst