Healthcare Provider Details

I. General information

NPI: 1770273963
Provider Name (Legal Business Name): STEPHANIE IWANCIOW BCBA - 1-13-14784
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 LOCUST ST
SANTA CRUZ CA
95060-3830
US

IV. Provider business mailing address

310 LOCUST ST
SANTA CRUZ CA
95060-3830
US

V. Phone/Fax

Practice location:
  • Phone: 408-308-8384
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-14784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: