MEDICARE: MS. STACY HAND UDOLPH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW18586	CA

General Provider Information

NPI Number	:	1245977032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACY HAND UDOLPH LCSW

Provider Business Mailing Address
First Line	:	PO BOX 983
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91365-0983
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 UNIVERSITY DR
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-8599
Country	:	US
Telephone Number	:	805-665-3710
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2022
Last Update Date	:	06/06/2023

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