Provider Demographics
NPI:1174090088
Name:SHIN, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SHIN
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:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-0437
Mailing Address - Country:US
Mailing Address - Phone:909-222-2431
Mailing Address - Fax:
Practice Address - Street 1:5673 LOS ROBLES
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-1661
Practice Address - Country:US
Practice Address - Phone:909-222-2431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2025-06-17
Deactivation Date:2022-10-26
Deactivation Code:
Reactivation Date:2022-11-10
Provider Licenses
StateLicense IDTaxonomies
CAAMFT136021101YM0800X
CA155173106H00000X
106S00000X, 225400000X, 390200000X
CALMFT155173106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program