Provider Demographics
NPI:1427836543
Name:BENEDICT, STACY A (LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:BENEDICT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 W JULIAN ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-2319
Mailing Address - Country:US
Mailing Address - Phone:408-314-6597
Mailing Address - Fax:
Practice Address - Street 1:373 W JULIAN ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-2319
Practice Address - Country:US
Practice Address - Phone:408-314-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA75166106H00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist