Provider Demographics
NPI:1740537117
Name:DALE, STEPHANIE ERIN (BCBA)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ERIN
Last Name:DALE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:ERIN
Other - Last Name:BLOOMFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:29390 QUAIL RUN DR
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-1565
Mailing Address - Country:US
Mailing Address - Phone:310-429-7214
Mailing Address - Fax:
Practice Address - Street 1:29390 QUAIL RUN DR
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-1565
Practice Address - Country:US
Practice Address - Phone:310-429-7214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-05
Last Update Date:2018-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-9008103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA82-0883361OtherELEV8 BEHAVIORAL TREATMENT