Healthcare Provider Details

I. General information

NPI: 1881197366
Provider Name (Legal Business Name): STACEY MARJEAN MOLINA BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 14TH ST
MODESTO CA
95354-1003
US

IV. Provider business mailing address

1811 GRAND CANAL BLVD STE 2
STOCKTON CA
95207-8107
US

V. Phone/Fax

Practice location:
  • Phone: 209-572-2589
  • Fax: 209-572-1461
Mailing address:
  • Phone: 209-345-1848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number18-49821
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-57600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: