Healthcare Provider Details

I. General information

NPI: 1194094342
Provider Name (Legal Business Name): STACEY ANN ZLOTNICK PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 WALL ST UNIT 296
LA JOLLA CA
92038-7013
US

IV. Provider business mailing address

1140 WALL ST UNIT 296
LA JOLLA CA
92038-7013
US

V. Phone/Fax

Practice location:
  • Phone: 619-354-8991
  • Fax:
Mailing address:
  • Phone: 619-354-8991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY32334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: