Stacey Nelson Clemenceau, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSY16162 Issued in CA

Practice address

820 Las Gallinas Ave
San Rafael, CA 94903-3410

Phone

(415) 444-3522

Fax

(415) 444-3019

NPI assigned

Dec 15, 2006

Last updated

Feb 11, 2022By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Dr. Stacey Nelson Former name

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Permanente Medical Group Inc

  • Internal Medicine Physician
  • Santa Clara, CA
  • NPI 1073606299
  Medicare reassignment NPD
• Permanente Medical Group Inc

  • Internal Medicine Physician
  • Stockton, CA
  • NPI 1548343510
  NPD
• Permanente Medical Group, Inc

  • Clinical Medical Laboratory
  • San Jose, CA
  • NPI 1497971584
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166140800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1644537600000",
    "number": "1265594113",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "820 LAS GALLINAS AVE",
            "city": "SAN RAFAEL",
            "state": "CA",
            "postal_code": "949033410",
            "telephone_number": "415-444-3522",
            "fax_number": "415-444-3019"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "820 LAS GALLINAS AVE",
            "city": "SAN RAFAEL",
            "state": "CA",
            "postal_code": "949033410",
            "telephone_number": "415-444-3522",
            "fax_number": "415-444-3019"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLEMENCEAU",
        "first_name": "STACEY",
        "middle_name": "NELSON",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-12-15",
        "last_updated": "2022-02-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSY16162",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ncalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "The Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "111 Smith Ranch Rd",
            "city": "San Rafael",
            "state": "CA",
            "country_code": "US",
            "postal_code": "94903",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "STACEY",
            "last_name": "NELSON",
            "prefix": "DR.",
            "credential": "PH.D.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Wade Clark, PHARM.D.
• Claudine Katherine Clarke, M. S.
• Nicole Marie Clausen, PHARM.D.
• Kaelen Clayton
• Tammy Swahn Cleland
• Cheryl Clementson
• Tiffany Ann Cleveland
• Jean Clinton, LPC
• Kelly Clohessy, LAC
• Gina Noelle Cloney, NP

• Clinical Psychologist in San Rafael, CA
• Providers in San Rafael, CA by specialty
• Clinical Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.