Provider Demographics
NPI:1043904212
Name:LEFAVOUR, STEPHANIE LEE (COUI)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEE
Last Name:LEFAVOUR
Suffix:
Gender:F
Credentials:COUI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22480 DUFF LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-6041
Mailing Address - Country:US
Mailing Address - Phone:208-965-4502
Mailing Address - Fax:
Practice Address - Street 1:22480 DUFF LN
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-6041
Practice Address - Country:US
Practice Address - Phone:208-965-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCOUI-9617101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional