Provider Demographics
NPI:1447828306
Name:STACY, RONALD ROY (13841-RAC)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:ROY
Last Name:STACY
Suffix:
Gender:M
Credentials:13841-RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 N 2ND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-1124
Mailing Address - Country:US
Mailing Address - Phone:619-426-4801
Mailing Address - Fax:
Practice Address - Street 1:73 N 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-1124
Practice Address - Country:US
Practice Address - Phone:619-426-4801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13841-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)