Provider Demographics
NPI:1861112203
Name:DOURTHE, STACIE B (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:B
Last Name:DOURTHE
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4346 EMPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-3507
Mailing Address - Country:US
Mailing Address - Phone:805-797-6495
Mailing Address - Fax:
Practice Address - Street 1:4346 EMPRESS AVE
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-3507
Practice Address - Country:US
Practice Address - Phone:805-797-6495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA577105163W00000X
CA2200364S00000X
CA95028676363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty