Provider Demographics
NPI:1669090346
Name:DEATHERAGE, STEPHANIE MARIE
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:DEATHERAGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21881 UTE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-3548
Mailing Address - Country:US
Mailing Address - Phone:949-290-0114
Mailing Address - Fax:
Practice Address - Street 1:3505 CADILLAC AVENUE
Practice Address - Street 2:BUILDING O, SUITE 110
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1429
Practice Address - Country:US
Practice Address - Phone:949-290-0114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1293631041C0700X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical