Provider Demographics
NPI:1053514679
Name:POULTER, STEPHAN BRETT (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:BRETT
Last Name:POULTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 SAN VICENTE BLVD STE 621
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6604
Mailing Address - Country:US
Mailing Address - Phone:310-480-8352
Mailing Address - Fax:
Practice Address - Street 1:11980 SAN VICENTE BLVD STE 621
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6604
Practice Address - Country:US
Practice Address - Phone:310-480-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-10
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13992103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical