Provider Demographics
NPI:1447913447
Name:RUSHATAKANKOVIT, STEFANIE LAI (LEP, BCBA)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:LAI
Last Name:RUSHATAKANKOVIT
Suffix:
Gender:F
Credentials:LEP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3848 W CARSON ST STE 307
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-6732
Mailing Address - Country:US
Mailing Address - Phone:424-307-5007
Mailing Address - Fax:
Practice Address - Street 1:3848 W CARSON ST STE 307
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6732
Practice Address - Country:US
Practice Address - Phone:424-307-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-16
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-15774103K00000X
CALEP3948103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool