Healthcare Provider Details

I. General information

NPI: 1982169827
Provider Name (Legal Business Name): STELLA TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 CARNEGIE DR STE 210
SAN BERNARDINO CA
92408-3548
US

IV. Provider business mailing address

621 CARNEGIE DR STE 210
SAN BERNARDINO CA
92408-3548
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW124653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: