Provider Demographics
NPI:1831614866
Name:MUTRYNOWSKI, STACY KATHRYN (LMFT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:KATHRYN
Last Name:MUTRYNOWSKI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 ADASON DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-3613
Mailing Address - Country:US
Mailing Address - Phone:818-613-3394
Mailing Address - Fax:
Practice Address - Street 1:2401 MERCED ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4228
Practice Address - Country:US
Practice Address - Phone:510-362-3553
Practice Address - Fax:510-618-5830
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130363106H00000X
CA108812106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist