Provider Demographics
NPI:1275783052
Name:STEPHENSON, GINA RENE
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:RENE
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:RENE
Other - Last Name:REARDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:879 W 190TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4223
Mailing Address - Country:US
Mailing Address - Phone:310-323-6887
Mailing Address - Fax:
Practice Address - Street 1:879 W 190TH ST STE 300
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4223
Practice Address - Country:US
Practice Address - Phone:310-323-6887
Practice Address - Fax:310-436-8285
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist