Healthcare Provider Details

I. General information

NPI: 1437888278
Provider Name (Legal Business Name): IAN BRADY STANLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 N SAN GABRIEL BLVD FL 1
PASADENA CA
91107-3429
US

IV. Provider business mailing address

6747 AMIGO AVE
RESEDA CA
91335-5310
US

V. Phone/Fax

Practice location:
  • Phone: 818-844-3376
  • Fax:
Mailing address:
  • Phone: 818-304-3069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: