Healthcare Provider Details

I. General information

NPI: 1871703900
Provider Name (Legal Business Name): STACY ANNETTE IVERY L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 BLAZEWOOD ST
RIVERSIDE CA
92507-5909
US

IV. Provider business mailing address

1200 BLAZEWOOD ST
RIVERSIDE CA
92507-5909
US

V. Phone/Fax

Practice location:
  • Phone: 951-377-1087
  • Fax: 951-683-3323
Mailing address:
  • Phone: 951-377-1087
  • Fax: 951-683-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberR51A (#070191978)
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 17495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: