Provider Demographics
NPI:1457590374
Name:STACCONE, SUZANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:STACCONE
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:PO BOX 22544
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-5144
Mailing Address - Country:US
Mailing Address - Phone:209-835-4141
Mailing Address - Fax:209-830-3974
Practice Address - Street 1:3177 PHOENIX LN
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94502-6924
Practice Address - Country:US
Practice Address - Phone:209-835-4141
Practice Address - Fax:209-830-3974
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21415103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist