Provider Demographics
NPI:1679253678
Name:SORADY-IVERSON, STEPHANIE R (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:SORADY-IVERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 OCEAN PARK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3029
Mailing Address - Country:US
Mailing Address - Phone:310-428-0395
Mailing Address - Fax:
Practice Address - Street 1:3130 BAGLEY AVE APT 108
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3063
Practice Address - Country:US
Practice Address - Phone:310-428-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1163911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical