Provider Demographics
NPI:1588406391
Name:SELEVITCH, STEPHANIE LEE (RAC)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LEE
Last Name:SELEVITCH
Suffix:
Gender:F
Credentials:RAC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LEE
Other - Last Name:SELEVITCH-WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RAC
Mailing Address - Street 1:4161 MARLBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1412
Mailing Address - Country:US
Mailing Address - Phone:619-282-7274
Mailing Address - Fax:
Practice Address - Street 1:4161 MARLBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1412
Practice Address - Country:US
Practice Address - Phone:619-282-7274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16905-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)