Healthcare Provider Details

I. General information

NPI: 1558266551
Provider Name (Legal Business Name): STEPHANIE CANSECO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 EL DORADO ST
CRESCENT CITY CA
95531-2111
US

IV. Provider business mailing address

2350 HOWLAND HILL RD
CRESCENT CITY CA
95531-9238
US

V. Phone/Fax

Practice location:
  • Phone: 707-464-0310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: