Provider Demographics
NPI:1134279581
Name:DANIEL, STEPHANIE JILL (MS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JILL
Last Name:DANIEL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4929
Mailing Address - Country:US
Mailing Address - Phone:304-256-7113
Mailing Address - Fax:304-256-7136
Practice Address - Street 1:209 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1413
Practice Address - Country:US
Practice Address - Phone:304-574-2100
Practice Address - Fax:304-574-2151
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1104103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY30615058Medicaid