Provider Demographics
NPI:1184018657
Name:STOVALL, VINICE
Entity Type:Individual
Prefix:
First Name:VINICE
Middle Name:
Last Name:STOVALL
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 1:4221 WILSHIRE BLVD STE 300A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3537
Mailing Address - Country:US
Mailing Address - Phone:888-428-3223
Mailing Address - Fax:
Practice Address - Street 1:312 S JUNIPER ST STE 202
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4998
Practice Address - Country:US
Practice Address - Phone:888-428-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health