Provider Demographics
NPI:1144606468
Name:DEFER, STACIA
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:DEFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7537 REESE RD LOT 23
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-9576
Mailing Address - Country:US
Mailing Address - Phone:307-221-2586
Mailing Address - Fax:
Practice Address - Street 1:7537 REESE RD LOT 23
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-9576
Practice Address - Country:US
Practice Address - Phone:307-221-2586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst