MEDICARE: STACEY M. BAYAN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PSY27111	CA

General Provider Information

NPI Number	:	1164807954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY M. BAYAN PSYD

Provider Business Mailing Address
First Line	:	1145 S GRAND AVE
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91740-5013
Country	:	US
Telephone Number	:	909-394-1667
Fax Number	:	909-575-4783

Provider Business Practice Location Address
First Line	:	1145 S GRAND AVE
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91740-5013
Country	:	US
Telephone Number	:	909-394-1667
Fax Number	:	909-575-4783

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2015
Last Update Date	:	05/06/2024

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