Provider Demographics
NPI:1871703900
Name:IVERY, STACY ANNETTE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANNETTE
Last Name:IVERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 BLAZEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-5909
Mailing Address - Country:US
Mailing Address - Phone:951-377-1087
Mailing Address - Fax:951-683-3323
Practice Address - Street 1:1200 BLAZEWOOD ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5909
Practice Address - Country:US
Practice Address - Phone:951-377-1087
Practice Address - Fax:951-683-3323
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR51A (#070191978)101YS0200X
CALCS 174951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical