Basic Information
| Provider Information | |||||||||
| NPI: | 1538889324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAUFFER | ||||||||
| FirstName: | SIERRA | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | MULE CREEK STATE PRISON 4001 CA-104 | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
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| Practice Location | |||||||||
| Address1: | MULE CREEK STATE PRISON | ||||||||
| Address2: | 4001 CA-104 | ||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092744911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 86994 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.