Provider Demographics
NPI:1548695620
Name:LAFONTAINE, STEPHANIE SOPHIA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SOPHIA
Last Name:LAFONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:SOPHIA
Other - Last Name:WOODHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5150 E PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3312
Mailing Address - Country:US
Mailing Address - Phone:562-490-7600
Mailing Address - Fax:562-490-7601
Practice Address - Street 1:5150 E PACIFIC COAST HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3312
Practice Address - Country:US
Practice Address - Phone:562-490-7600
Practice Address - Fax:562-490-7601
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLMFT10228106H00000X
NVMI0470172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#95-2633765OtherMEDI-CAL