Provider Demographics
NPI:1972266393
Name:STEPHENSON, KELLY (CMA, RADT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:CMA, RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W OLIVE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-6093
Mailing Address - Country:US
Mailing Address - Phone:714-718-7814
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4296
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1447811021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)