Healthcare Provider Details

I. General information

NPI: 1679389514
Provider Name (Legal Business Name): STEPPING FORWARD GROUP PROFESSIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15375 BARRANCA PKWY STE D
IRVINE CA
92618-2206
US

IV. Provider business mailing address

15375 BARRANCA PKWY STE A201
IRVINE CA
92618-2204
US

V. Phone/Fax

Practice location:
  • Phone: 949-333-1209
  • Fax: 949-333-1209
Mailing address:
  • Phone: 949-280-9254
  • Fax: 949-333-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GARY PEDNEAULT
Title or Position: MD
Credential: MD
Phone: 949-333-1209