Healthcare Provider Details

I. General information

NPI: 1851427009
Provider Name (Legal Business Name): STACEY ANN BUENAVISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 ARLINGTON DR
SAN LEANDRO CA
94578-1132
US

IV. Provider business mailing address

8405 BOLEY DR
STOCKTON CA
95212-3456
US

V. Phone/Fax

Practice location:
  • Phone: 510-317-1437
  • Fax:
Mailing address:
  • Phone: 209-473-3808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: