Healthcare Provider Details

I. General information

NPI: 1649717323
Provider Name (Legal Business Name): STACEY KING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

25124 FIR AVE APT 44
MORENO VALLEY CA
92553-2307
US

V. Phone/Fax

Practice location:
  • Phone: 909-781-1596
  • Fax:
Mailing address:
  • Phone: 951-255-1320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW119115
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: