Provider Demographics
NPI:1346628898
Name:SEPERNIA, STEPHAN (MA IN CLINICAL PSYCH)
Entity Type:Individual
Prefix:MR
First Name:STEPHAN
Middle Name:
Last Name:SEPERNIA
Suffix:
Gender:M
Credentials:MA IN CLINICAL PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 N. CROFT AVE. # 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069
Mailing Address - Country:US
Mailing Address - Phone:213-804-0444
Mailing Address - Fax:
Practice Address - Street 1:5601 W. SLAVSON AVE. #192
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:310-968-6648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF65152106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist