Healthcare Provider Details

I. General information

NPI: 1215409875
Provider Name (Legal Business Name): STACEY HEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 H ST APT 12
SACRAMENTO CA
95816-4341
US

IV. Provider business mailing address

6400 TUPELO DR
CITRUS HEIGHTS CA
95621-1741
US

V. Phone/Fax

Practice location:
  • Phone: 480-635-2308
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: