Provider Demographics
NPI:1427245323
Name:MERRELL, STACEY LEE (LMFT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:MERRELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7365 CARNELIAN ST
Mailing Address - Street 2:202
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1158
Mailing Address - Country:US
Mailing Address - Phone:951-218-0951
Mailing Address - Fax:877-850-5695
Practice Address - Street 1:7365 CARNELIAN ST
Practice Address - Street 2:202
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1158
Practice Address - Country:US
Practice Address - Phone:951-218-0951
Practice Address - Fax:877-850-5695
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 46624106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist