Provider Demographics
NPI:1154023570
Name:DAVIS, STEPHANIE LYNNE (PHD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNNE
Other - Last Name:DEVERICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26691 PLAZA STE 221
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8582
Mailing Address - Country:US
Mailing Address - Phone:949-534-2623
Mailing Address - Fax:
Practice Address - Street 1:26691 PLAZA STE 221
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8582
Practice Address - Country:US
Practice Address - Phone:949-534-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30293103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist