Provider Demographics
NPI:1770341638
Name:BEAL, STACEY CHARLENE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:CHARLENE
Last Name:BEAL
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 1:200 W SANTA ANA BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-7552
Mailing Address - Country:US
Mailing Address - Phone:714-480-6767
Mailing Address - Fax:
Practice Address - Street 1:200 W SANTA ANA BLVD STE 1000
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-7552
Practice Address - Country:US
Practice Address - Phone:714-480-6641
Practice Address - Fax:714-568-4362
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-PQBHKF175T00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes175T00000XOther Service ProvidersPeer Specialist