=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245376607
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY ANN HAYWOOD MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4545 PARK BLVD STE 104
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92116-2668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-743-1039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 623 SANTA ROSITA
-----------------------------------------------------
City | SOLANA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92075-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-743-1039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 16964
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------