Healthcare Provider Details

I. General information

NPI: 1669764429
Provider Name (Legal Business Name): STACY T TAMAYO IMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 W AVENUE J STE C
LANCASTER CA
93534-3443
US

IV. Provider business mailing address

921 W AVENUE J STE C
LANCASTER CA
93534-3443
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-0131
  • Fax: 661-729-8912
Mailing address:
  • Phone: 661-949-0131
  • Fax: 661-729-8912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number62460
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53596
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC53596
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: