Provider Demographics
NPI:1154944023
Name:SADAKA, STEPHANIE LAKE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAKE
Last Name:SADAKA
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 1:21382 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9754
Mailing Address - Country:US
Mailing Address - Phone:909-694-6028
Mailing Address - Fax:
Practice Address - Street 1:21382 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9754
Practice Address - Country:US
Practice Address - Phone:909-694-6028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst