Provider Demographics
NPI:1215147640
Name:VIZCAINO, STEPHANIE LYNN
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:VIZCAINO
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 1:1417 THRUSH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2063
Mailing Address - Country:US
Mailing Address - Phone:510-317-4791
Mailing Address - Fax:
Practice Address - Street 1:1417 THRUSH AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2063
Practice Address - Country:US
Practice Address - Phone:510-317-4791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)