MEDICARE: IAN GABRIEL STANLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1053268961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN GABRIEL STANLEY

Provider Business Mailing Address
First Line	:	2369 MEADOW WAY APT 106
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-6389
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2369 MEADOW WAY APT 106
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-6389
Country	:	US
Telephone Number	:	707-501-8603
Fax Number	:	707-501-8603

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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Directions to “ IAN GABRIEL STANLEY ” Practice Location

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