Provider Demographics
NPI:1932402310
Name:WHITESIDE, STACY NICOLE
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:NICOLE
Other - Last Name:SENSALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 MUIR RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4668
Mailing Address - Country:US
Mailing Address - Phone:925-370-4715
Mailing Address - Fax:
Practice Address - Street 1:150 MUIR RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4668
Practice Address - Country:US
Practice Address - Phone:925-370-4715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical