Provider Demographics
NPI:1174974570
Name:YELDELL, STACIE (MA,, MT-BC, AVPT)
Entity type:Individual
Prefix:MS
First Name:STACIE
Middle Name:
Last Name:YELDELL
Suffix:
Gender:F
Credentials:MA,, MT-BC, AVPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4212
Mailing Address - Country:US
Mailing Address - Phone:424-230-6335
Mailing Address - Fax:
Practice Address - Street 1:552 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-4212
Practice Address - Country:US
Practice Address - Phone:424-230-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA07920225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist