Provider Demographics
NPI:1639426265
Name:CRAWFORD, STEPHANIE LOIS WALTON NORIEGA
Entity Type:Individual
Prefix:
First Name:STEPHANIE LOIS
Middle Name:WALTON NORIEGA
Last Name:CRAWFORD
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 1:1617 CRAVENS AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-3203
Mailing Address - Country:US
Mailing Address - Phone:310-328-0855
Mailing Address - Fax:310-328-9636
Practice Address - Street 1:1617 CRAVENS AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-3203
Practice Address - Country:US
Practice Address - Phone:310-328-0855
Practice Address - Fax:310-328-9636
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CA76079106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program