Provider Demographics
NPI:1376791194
Name:MIN, STEPHANIE Y
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:Y
Last Name:MIN
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 1:9808 VENICE BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6824
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:310-840-7023
Practice Address - Street 1:8401 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3423
Practice Address - Country:US
Practice Address - Phone:323-789-6492
Practice Address - Fax:323-967-0180
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL SECURITY NUMBER