Healthcare Provider Details

I. General information

NPI: 1942582283
Provider Name (Legal Business Name): STEPHANIE MUSHRUSH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17707 STUDEBAKER RD # 208
CERRITOS CA
90703-2640
US

IV. Provider business mailing address

17707 STUDEBAKER RD
CERRITOS CA
90703-2640
US

V. Phone/Fax

Practice location:
  • Phone: 562-402-0677
  • Fax: 562-467-7478
Mailing address:
  • Phone: 562-402-0677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number76738
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: