Healthcare Provider Details

I. General information

NPI: 1285455717
Provider Name (Legal Business Name): STEPHANIE GLENN
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: FRANKIE GAVAZZA

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 G ST STE 4
ARCATA CA
95521-6247
US

IV. Provider business mailing address

1745 EDELINE AVE
MCKINLEYVILLE CA
95519-4105
US

V. Phone/Fax

Practice location:
  • Phone: 707-502-2083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number148813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: