Provider Demographics
NPI:1144884107
Name:KOSTELNIK, STEVIE
Entity type:Individual
Prefix:MISS
First Name:STEVIE
Middle Name:
Last Name:KOSTELNIK
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 1:421 E MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0437
Mailing Address - Country:US
Mailing Address - Phone:209-558-7494
Mailing Address - Fax:209-558-8918
Practice Address - Street 1:121 DOWNEY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1208
Practice Address - Country:US
Practice Address - Phone:209-341-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2509194405300000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No405300000XOther Service ProvidersPrevention Professional