Provider Demographics
NPI:1063196335
Name:VARGAS, STACEY JANE (LEP, PPS)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:JANE
Last Name:VARGAS
Suffix:
Gender:F
Credentials:LEP, PPS
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:JANE
Other - Last Name:STRETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9924 BELLA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5401
Mailing Address - Country:US
Mailing Address - Phone:951-743-4689
Mailing Address - Fax:
Practice Address - Street 1:9924 BELLA VISTA DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5401
Practice Address - Country:US
Practice Address - Phone:951-743-4689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP4163103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool