Basic Information
Provider Information | |||||||||
NPI: | 1497194328 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEFANELLI | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY. D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOMEZ | ||||||||
OtherFirstName: | STEPHANIE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSY. D | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4851 TORIDA WAY | ||||||||
Address2: |   | ||||||||
City: | YORBA LINDA | ||||||||
State: | CA | ||||||||
PostalCode: | 928863635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512524978 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2050 YOUTH WAY | ||||||||
Address2: | BLDG 1 | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928353819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148719264 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2013 | ||||||||
LastUpdateDate: | 04/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY27869 | CA | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.