Provider Demographics
NPI:1104251800
Name:NORDWALL, STACEY ANN
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ANN
Last Name:NORDWALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-3572
Mailing Address - Country:US
Mailing Address - Phone:510-428-3885
Mailing Address - Fax:
Practice Address - Street 1:380 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-3572
Practice Address - Country:US
Practice Address - Phone:510-428-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor