Provider Demographics
NPI:1104849751
Name:DANIEL, STACIA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:STACIA
Middle Name:MARIE
Last Name:DANIEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21714 HARDY OAK BLVD
Mailing Address - Street 2:UNIT #104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4838
Mailing Address - Country:US
Mailing Address - Phone:210-490-9062
Mailing Address - Fax:
Practice Address - Street 1:21714 HARDY OAK BLVD
Practice Address - Street 2:UNIT #104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4838
Practice Address - Country:US
Practice Address - Phone:210-490-9062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30792103T00000X, 103TB0200X, 103TC1900X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1794141Medicaid
TX1794141Medicaid