Provider Demographics
NPI:1679880249
Name:SHADOFF, STACEY J (MFT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:SHADOFF
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 S JONES BLVD # 227
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3103
Mailing Address - Country:US
Mailing Address - Phone:702-214-2140
Mailing Address - Fax:702-215-5821
Practice Address - Street 1:2350 S JONES BLVD # 227
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3103
Practice Address - Country:US
Practice Address - Phone:702-214-2140
Practice Address - Fax:702-215-5821
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39346101YM0800X
CA39346103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health