Provider Demographics
NPI:1063621308
Name:DRUCKER, STANTON M (LCSW)
Entity type:Individual
Prefix:MR
First Name:STANTON
Middle Name:M
Last Name:DRUCKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 261
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-0261
Mailing Address - Country:US
Mailing Address - Phone:530-926-2542
Mailing Address - Fax:530-926-3953
Practice Address - Street 1:101 E ALMA ST
Practice Address - Street 2:SUITE 302
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2288
Practice Address - Country:US
Practice Address - Phone:530-926-2542
Practice Address - Fax:530-926-3953
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS185621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ15161ZMedicare ID - Type Unspecified