Provider Demographics
NPI:1538381249
Name:GAINOK, STACY (IMFT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GAINOK
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 PENTUCKETT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5737
Mailing Address - Country:US
Mailing Address - Phone:619-210-0162
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5391
Practice Address - Country:US
Practice Address - Phone:858-410-1067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF46173106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist