Provider Demographics
NPI:1588676282
Name:CARSON, STEPHANIE A (LMFT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:CARSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11780 CENTRAL AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-6498
Mailing Address - Country:US
Mailing Address - Phone:909-364-1104
Mailing Address - Fax:
Practice Address - Street 1:11780 CENTRAL AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-6498
Practice Address - Country:US
Practice Address - Phone:909-364-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39272106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist