Provider Demographics
NPI:1174062780
Name:AREVALO, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:AREVALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15783 HARSHAW PL
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-5441
Mailing Address - Country:US
Mailing Address - Phone:714-603-6063
Mailing Address - Fax:
Practice Address - Street 1:15783 HARSHAW PL
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-5441
Practice Address - Country:US
Practice Address - Phone:714-603-6063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA1175971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174062780Medicaid