Provider Demographics
NPI:1962578559
Name:KOMORI STAGER, MARC D (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:D
Last Name:KOMORI STAGER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S MAIN ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5340
Mailing Address - Country:US
Mailing Address - Phone:925-325-5022
Mailing Address - Fax:
Practice Address - Street 1:1600 S MAIN ST
Practice Address - Street 2:SUITE 225
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5340
Practice Address - Country:US
Practice Address - Phone:925-325-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21734103T00000X
103TF0000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent