Provider Demographics
NPI:1073870754
Name:CARRION, STEPHANIE DIANA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANA
Last Name:CARRION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 VENICE BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5059
Mailing Address - Country:US
Mailing Address - Phone:310-406-5434
Mailing Address - Fax:
Practice Address - Street 1:6666 GREEN VALLEY CIR
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-7068
Practice Address - Country:US
Practice Address - Phone:310-846-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health