Provider Demographics
NPI:1831600162
Name:IMP, STEPHANIE T
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:T
Last Name:IMP
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:P.O. BOX 6299
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607
Mailing Address - Country:US
Mailing Address - Phone:714-972-0040
Mailing Address - Fax:714-460-2010
Practice Address - Street 1:2107 N BROADWAY
Practice Address - Street 2:SUITE 207
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706
Practice Address - Country:US
Practice Address - Phone:714-972-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
94023427103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool