Provider Demographics
NPI:1073150728
Name:WILSON, STEFFEN POPE (PHD, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:STEFFEN
Middle Name:POPE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 PINE RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514-1770
Mailing Address - Country:US
Mailing Address - Phone:859-536-1527
Mailing Address - Fax:
Practice Address - Street 1:1421 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1059
Practice Address - Country:US
Practice Address - Phone:859-624-2454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252438103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst