Provider Demographics
NPI:1669062089
Name:DEMARANVILLE, STACY LYNN (BCBA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:DEMARANVILLE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11802 N 91ST PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6869
Mailing Address - Country:US
Mailing Address - Phone:949-500-4967
Mailing Address - Fax:
Practice Address - Street 1:2730 S VAL VISTA DR BLDG 4
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1675
Practice Address - Country:US
Practice Address - Phone:949-500-4967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-45172103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-45172OtherBACB CERTIFICATION NUMBER