Healthcare Provider Details

I. General information

NPI: 1588384457
Provider Name (Legal Business Name): STACEY LISETTE CUEVAS AGUAYO AMFT, APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8350 ARCHIBALD AVE STE 110
RANCHO CUCAMONGA CA
91730-3670
US

IV. Provider business mailing address

PO BOX 2962
FONTANA CA
92334-2962
US

V. Phone/Fax

Practice location:
  • Phone: 909-527-3463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10144
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number126591
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: