Provider Demographics
NPI:1972156362
Name:BOTTOMS, STACEY KATHLEEN (AMFT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:KATHLEEN
Last Name:BOTTOMS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 STONYFORD DRIVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4358
Mailing Address - Country:US
Mailing Address - Phone:707-344-0699
Mailing Address - Fax:
Practice Address - Street 1:1234 EMPIRE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5711
Practice Address - Country:US
Practice Address - Phone:510-317-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122725106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist