Provider Demographics
NPI:1114434495
Name:YSLAVA, STEPHANIE R (MOTR/L)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:R
Last Name:YSLAVA
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:GERVAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 E. HIGHLAND AVE
Mailing Address - Street 2:404
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-5449
Mailing Address - Country:US
Mailing Address - Phone:909-649-2585
Mailing Address - Fax:
Practice Address - Street 1:1200 E. HIGHLAND AVE
Practice Address - Street 2:404
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-5449
Practice Address - Country:US
Practice Address - Phone:909-649-2585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16160225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist