Provider Demographics
NPI:1740941160
Name:MASTERSON, STEPHANIE MALAINE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MALAINE
Last Name:MASTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MALAINE
Other - Last Name:MASTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9319 KAREN AVE
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-1228
Mailing Address - Country:US
Mailing Address - Phone:661-584-2265
Mailing Address - Fax:
Practice Address - Street 1:16940 HIGHWAY 14 STE F
Practice Address - Street 2:
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1238
Practice Address - Country:US
Practice Address - Phone:661-824-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)