Provider Demographics
NPI:1336274968
Name:ANDERSON, STACEY A (PHD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:A
Last Name:ANDERSON
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 1:11311 S STEPHANIE DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-5862
Mailing Address - Country:US
Mailing Address - Phone:928-287-5901
Mailing Address - Fax:928-342-1331
Practice Address - Street 1:11311 S STEPHANIE DR
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-5862
Practice Address - Country:US
Practice Address - Phone:928-287-5901
Practice Address - Fax:928-342-1331
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
AZ4068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool