Provider Demographics
NPI:1003347386
Name:EVANS-WONDRA, STEPHANIE LYNN (MA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:EVANS-WONDRA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 34TH PL
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-8936
Mailing Address - Country:US
Mailing Address - Phone:541-999-9154
Mailing Address - Fax:
Practice Address - Street 1:1220 34TH PL
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-8936
Practice Address - Country:US
Practice Address - Phone:541-999-9154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3417101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health