Basic Information
| Provider Information | |||||||||
| NPI: | 1891430047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLATTERY | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | AMFT131751 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 762 9TH ST APT 3 | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955313452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074647224 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 455 K ST | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955314107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074647224 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2022 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | AMFT131751 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.