Provider Demographics
NPI:1770213712
Name:GADDIS, STACI MICHELLE
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:MICHELLE
Last Name:GADDIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CAMINO DEL RIO S STE ITE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3504
Mailing Address - Country:US
Mailing Address - Phone:619-436-4020
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S STE ITE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3504
Practice Address - Country:US
Practice Address - Phone:619-436-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator