Provider Demographics
NPI:1447461397
Name:SIMONE, STACY (MA)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:SIMONE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:ANA
Other - Last Name:RUSSAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:600 N ALAMEDA ST EAST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-2605
Mailing Address - Country:US
Mailing Address - Phone:323-242-5000
Mailing Address - Fax:
Practice Address - Street 1:600 N ALAMEDA ST EAST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221
Practice Address - Country:US
Practice Address - Phone:323-242-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48661106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist