Healthcare Provider Details

I. General information

NPI: 1659693349
Provider Name (Legal Business Name): STEPHANIE ERIKA BAZURTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W LA VETA AVE
ORANGE CA
92868
US

IV. Provider business mailing address

2910 BRADFORD PL APT D
SANTA ANA CA
92707-4021
US

V. Phone/Fax

Practice location:
  • Phone: 888-770-2462
  • Fax:
Mailing address:
  • Phone: 714-600-4341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: