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General NPI Number Information
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NPI Number | 1396875779
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Entity Type | Individual
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Provider Name | STACY DE VRIES BOSTROM MSW
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Gender | Female
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 474 W VERMONT AVE SUITE 103
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City | ESCONDIDO
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State | CA
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Zip | 92025-6584
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Country | US
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Telephone | 760-745-0281
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Fax |
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Provider Business Mailing Address
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Address Line | 930 VIA MIL CUMBRES UNIT 53
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City | SOLANA BEACH
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State | CA
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Zip | 92075-1700
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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