Healthcare Provider Details

I. General information

NPI: 1841564259
Provider Name (Legal Business Name): STACY WAITE-OCAMPO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 OAKDALE RD STE 800
MODESTO CA
95355
US

IV. Provider business mailing address

1317 OAKDALE RD STE 800
MODESTO CA
95355
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-4791
  • Fax: 209-521-4794
Mailing address:
  • Phone: 209-521-4791
  • Fax: 209-521-4794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-5511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: