Provider Demographics
NPI:1164106019
Name:GEORGE, STEPHANIE RENEE (PSYD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-4339
Mailing Address - Country:US
Mailing Address - Phone:774-402-4758
Mailing Address - Fax:
Practice Address - Street 1:14 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-4339
Practice Address - Country:US
Practice Address - Phone:774-402-4758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MANA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist