Provider Demographics
NPI:1104959691
Name:DEMERY, STEPHANIE KINLOCH (IMF 45317)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:KINLOCH
Last Name:DEMERY
Suffix:
Gender:F
Credentials:IMF 45317
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:C
Other - Last Name:KINLOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IMF 45317
Mailing Address - Street 1:11911 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE #280
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5086
Mailing Address - Country:US
Mailing Address - Phone:310-684-3899
Mailing Address - Fax:
Practice Address - Street 1:11911 SAN VICENTE BLVD
Practice Address - Street 2:SUITE #280
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5086
Practice Address - Country:US
Practice Address - Phone:310-684-3899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 45317106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist