Healthcare Provider Details

I. General information

NPI: 1427446947
Provider Name (Legal Business Name): ALEXANDRA IVANOVSKY STOBAUGH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 09/13/2025
Certification Date: 09/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6731 SHOO FLY RD
PLACERVILLE CA
95667-7421
US

IV. Provider business mailing address

PO BOX 1403
PLACERVILLE CA
95667-1403
US

V. Phone/Fax

Practice location:
  • Phone: 530-363-8681
  • Fax:
Mailing address:
  • Phone: 530-363-8681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25034
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number25034
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25034
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number25034
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: