Provider Demographics
NPI:1871177618
Name:PALMER, STACIE (MFT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:PALMER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:SHAHEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT
Mailing Address - Street 1:16966 AVENIDA DE SANTA YNEZ
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-2165
Mailing Address - Country:US
Mailing Address - Phone:310-569-6970
Mailing Address - Fax:
Practice Address - Street 1:16966 AVENIDA DE SANTA YNEZ
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-2165
Practice Address - Country:US
Practice Address - Phone:310-569-6970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT37452106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist