Provider Demographics
NPI:1881119113
Name:PEAK, STACEY SU-CHIO (PSYD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:SU-CHIO
Last Name:PEAK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:SU-CHIO
Other - Last Name:POON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 5236
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-5236
Mailing Address - Country:US
Mailing Address - Phone:510-387-3635
Mailing Address - Fax:
Practice Address - Street 1:35 E 10TH ST STE E3
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4066
Practice Address - Country:US
Practice Address - Phone:209-210-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY32621103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program