Provider Demographics
NPI:1578074852
Name:STEPHENS, GWEN (MA)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
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Mailing Address - Street 1:18726 S WESTERN AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3858
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:4030 MOORPARK AVE STE 105
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1848
Practice Address - Country:US
Practice Address - Phone:669-444-5980
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
45-3589857OtherTHE HOLMAN GROUP