Provider Demographics
NPI:1174968655
Name:PETRENKO, STEPHANIE LAUREN BIBEAU (MA, BCBA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAUREN BIBEAU
Last Name:PETRENKO
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MONTEBELLO BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N MONTEBELLO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4269
Practice Address - Country:US
Practice Address - Phone:132-383-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-13306103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst