Provider Demographics
NPI:1114561404
Name:ANDERSON, STELLA TREVINO
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:TREVINO
Last Name:ANDERSON
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 1:2703 ADDISON AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2316
Mailing Address - Country:US
Mailing Address - Phone:512-773-3260
Mailing Address - Fax:
Practice Address - Street 1:3403B GARDEN VILLA LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6915
Practice Address - Country:US
Practice Address - Phone:407-718-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst