Provider Demographics
NPI:1780498741
Name:CLATIION, STEPHANIE ALICIA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALICIA
Last Name:CLATIION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7398
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-7398
Mailing Address - Country:US
Mailing Address - Phone:951-519-4724
Mailing Address - Fax:
Practice Address - Street 1:930 S MOUNT VERNON AVE STE 90
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3928
Practice Address - Country:US
Practice Address - Phone:909-660-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA173089297Medicaid