Healthcare Provider Details

I. General information

NPI: 1639582976
Provider Name (Legal Business Name): STEPHANIE MARIE CHIQUILLO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date: 10/04/2023
Reactivation Date: 07/23/2024

III. Provider practice location address

3143 MISSION ST
SAN FRANCISCO CA
94110-4503
US

IV. Provider business mailing address

3143 MISSION ST
SAN FRANCISCO CA
94110-4503
US

V. Phone/Fax

Practice location:
  • Phone: 415-872-7458
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: