Healthcare Provider Details

I. General information

NPI: 1942524475
Provider Name (Legal Business Name): STEPHEN THOMAS PRYSTASH LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28364 VINCENT MORAGA DR
TEMECULA CA
92590-3656
US

IV. Provider business mailing address

32654 VIA PERALES
TEMECULA CA
92592-8148
US

V. Phone/Fax

Practice location:
  • Phone: 951-526-4118
  • Fax: 951-602-6166
Mailing address:
  • Phone: 951-526-4118
  • Fax: 951-602-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMF24093
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: