Healthcare Provider Details

I. General information

NPI: 1093377657
Provider Name (Legal Business Name): STEPHANIE SO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E HARVARD ST
GLENDALE CA
91205-1114
US

IV. Provider business mailing address

501 E HARVARD ST
GLENDALE CA
91205-1114
US

V. Phone/Fax

Practice location:
  • Phone: 310-999-3122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2834287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: