Provider Demographics
NPI:1568669422
Name:STOUDEMIRE, IYANNA
Entity Type:Individual
Prefix:
First Name:IYANNA
Middle Name:
Last Name:STOUDEMIRE
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 1:1926 W 138TH ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90222-3128
Mailing Address - Country:US
Mailing Address - Phone:310-493-1321
Mailing Address - Fax:
Practice Address - Street 1:4390 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6237
Practice Address - Country:US
Practice Address - Phone:310-603-6949
Practice Address - Fax:310-603-6949
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2023-05-10
Deactivation Date:2019-07-18
Deactivation Code:
Reactivation Date:2019-09-30
Provider Licenses
StateLicense IDTaxonomies
CA69755106H00000X
CA108949101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist