Provider Demographics
NPI:1396232765
Name:SHAVER, STACIA
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:SHAVER
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 1:300 H ST
Mailing Address - Street 2:
Mailing Address - City:NEEDLES
Mailing Address - State:CA
Mailing Address - Zip Code:92363-2928
Mailing Address - Country:US
Mailing Address - Phone:760-326-4590
Mailing Address - Fax:760-326-3154
Practice Address - Street 1:300 H ST
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-2928
Practice Address - Country:US
Practice Address - Phone:760-326-4590
Practice Address - Fax:760-326-3154
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator