Provider Demographics
NPI:1437888278
Name:STANLEY, IAN BRADY
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:BRADY
Last Name:STANLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6747 AMIGO AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-5310
Mailing Address - Country:US
Mailing Address - Phone:818-304-3069
Mailing Address - Fax:
Practice Address - Street 1:253 N SAN GABRIEL BLVD FL 1
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3429
Practice Address - Country:US
Practice Address - Phone:818-844-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician