Provider Demographics
NPI:1720479132
Name:STONE RIDGE ACADEMY
Entity Type:Organization
Organization Name:STONE RIDGE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID-NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:650-863-4487
Mailing Address - Street 1:1115 E PUENTE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3261
Mailing Address - Country:US
Mailing Address - Phone:626-331-5900
Mailing Address - Fax:
Practice Address - Street 1:1115 E PUENTE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3261
Practice Address - Country:US
Practice Address - Phone:626-331-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-07
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency