Provider Demographics
NPI:1083932115
Name:GREGORY, STEPHANIE KOSUT (LPC-S)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KOSUT
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:JO
Other - Last Name:KOSUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:620 LONGMIRE RD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1819
Mailing Address - Country:US
Mailing Address - Phone:936-443-9629
Mailing Address - Fax:855-443-9630
Practice Address - Street 1:620 LONGMIRE RD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1819
Practice Address - Country:US
Practice Address - Phone:936-443-9629
Practice Address - Fax:855-443-9630
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2023-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65424101YA0400X, 101Y00000X, 101YM0800X, 101YP2500X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2200156-03Medicaid