Healthcare Provider Details

I. General information

NPI: 1750560769
Provider Name (Legal Business Name): STACEY SUZANNE KOPECKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST
SAN BERNARDINO CA
92408-2706
US

IV. Provider business mailing address

3836 WESSON RANCH RD
MODESTO CA
95356-1123
US

V. Phone/Fax

Practice location:
  • Phone: 909-388-9191
  • Fax: 909-388-9195
Mailing address:
  • Phone: 209-380-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW 28043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: