Provider Demographics
NPI:1053019661
Name:BALLIET, STACI
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:BALLIET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1585 HONEYWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-2735
Mailing Address - Country:US
Mailing Address - Phone:714-510-0101
Mailing Address - Fax:
Practice Address - Street 1:1585 HONEYWOOD CT
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-2735
Practice Address - Country:US
Practice Address - Phone:714-510-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1096311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty