Provider Demographics
NPI:1952137788
Name:BOLYARD, STACEY LYNN (EDD, PPS)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYNN
Last Name:BOLYARD
Suffix:
Gender:F
Credentials:EDD, PPS
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:BAMFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PPS
Mailing Address - Street 1:4210 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-6337
Mailing Address - Country:US
Mailing Address - Phone:510-657-2350
Mailing Address - Fax:
Practice Address - Street 1:4210 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-6337
Practice Address - Country:US
Practice Address - Phone:510-657-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200204775101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool