Basic Information
| Provider Information | |||||||||
| NPI: | 1225128002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19231 VICTORY BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913356308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187084500 | ||||||||
| FaxNumber: | 8186541956 | ||||||||
| Practice Location | |||||||||
| Address1: | 19231 VICTORY BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913356308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187084500 | ||||||||
| FaxNumber: | 8186541956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY 14119 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | PSY 14119 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TM1800X | PSY 14119 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103T00000X | PSY 14119 | CA | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.