Provider Demographics
NPI:1447471891
Name:RODGERS, STACEY M (PSYD)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:M
Last Name:RODGERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DEER PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2208
Mailing Address - Country:US
Mailing Address - Phone:415-577-3415
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE STE 108-B
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2141
Practice Address - Country:US
Practice Address - Phone:415-454-1605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20102103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL201020OtherBLUESHIELD