Provider Demographics
NPI:1740456946
Name:STAGNARO, OLIVIA KACEY
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KACEY
Last Name:STAGNARO
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 1:3935 NORMAL ST APT 106
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3586
Mailing Address - Country:US
Mailing Address - Phone:619-517-9440
Mailing Address - Fax:
Practice Address - Street 1:3935 NORMAL ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3585
Practice Address - Country:US
Practice Address - Phone:858-220-9916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138442106H00000X
322D00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children