Provider Demographics
NPI:1427275593
Name:EVANS, STEPHANIE SULLIVAN (LMFT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SULLIVAN
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 SAN RODOLFO DR # 1013
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2001
Mailing Address - Country:US
Mailing Address - Phone:858-519-8682
Mailing Address - Fax:
Practice Address - Street 1:3060 CAMINTO TERCER VERDE
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014
Practice Address - Country:US
Practice Address - Phone:858-519-8682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43692106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN