Provider Demographics
NPI:1497500177
Name:LILLARD, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LILLARD
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 1:15638 ATLANTUS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94579-2710
Mailing Address - Country:US
Mailing Address - Phone:510-364-6591
Mailing Address - Fax:
Practice Address - Street 1:4400 ALMA AVE
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-3104
Practice Address - Country:US
Practice Address - Phone:510-364-6591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool