Provider Demographics
NPI:1447346911
Name:GREEN, STACY L
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 W. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-477-9800
Mailing Address - Fax:530-477-9803
Practice Address - Street 1:714 WEST MAIN ST.
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-477-9800
Practice Address - Fax:530-477-9803
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAASW31786101YM0800X, 104100000X
CAASW16266104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker