Provider Demographics
NPI:1548333651
Name:ARCHER, STACY ANNE (BA, MA)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANNE
Last Name:ARCHER
Suffix:
Gender:F
Credentials:BA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 BOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1104
Mailing Address - Country:US
Mailing Address - Phone:408-807-5273
Mailing Address - Fax:
Practice Address - Street 1:2429 BOXWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1104
Practice Address - Country:US
Practice Address - Phone:408-807-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT80505106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3483OtherCOUNTY IDENTIFICATION