Provider Demographics
NPI:1063989309
Name:ETTLING, STEPHANIE ANNE (MA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:ETTLING
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22020 CLARENDON ST STE 208
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6322
Mailing Address - Country:US
Mailing Address - Phone:310-985-4081
Mailing Address - Fax:
Practice Address - Street 1:22020 CLARENDON ST STE 208
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6322
Practice Address - Country:US
Practice Address - Phone:310-985-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109865106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist