Provider Demographics
NPI:1295004091
Name:GAXIOLA, STEPHANIE R (MSW, LCSW, LICSW, MP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:R
Last Name:GAXIOLA
Suffix:
Gender:F
Credentials:MSW, LCSW, LICSW, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16710 VENTURA BLVD
Mailing Address - Street 2:#403
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1713
Mailing Address - Country:US
Mailing Address - Phone:415-694-8465
Mailing Address - Fax:
Practice Address - Street 1:16710 VENTURA BLVD
Practice Address - Street 2:#403
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1713
Practice Address - Country:US
Practice Address - Phone:415-694-8465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490121921041C0700X
MA1146571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical