=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902082167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY SOARES MA, MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2008
-----------------------------------------------------
Last Update Date | 01/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SOUTH 101 FOREST AVE
-----------------------------------------------------
City | SONORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-588-8993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1148
-----------------------------------------------------
City | SOULSBYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95372-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-588-8993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT 41684
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------