Healthcare Provider Details

I. General information

NPI: 1477755122
Provider Name (Legal Business Name): STEPHANIE DAWN VAN TUYL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10929 SOUTH ST
CERRITOS CA
90703-5340
US

IV. Provider business mailing address

308 11TH ST
HUNTINGTON BEACH CA
92648-4506
US

V. Phone/Fax

Practice location:
  • Phone: 562-924-5526
  • Fax: 562-923-3273
Mailing address:
  • Phone: 714-234-7511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF53481
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC49101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: