Provider Demographics
NPI:1255833885
Name:STEPHENSON-TAYLOR, KESSA MYSTIQUE (AA, BA)
Entity Type:Individual
Prefix:
First Name:KESSA
Middle Name:MYSTIQUE
Last Name:STEPHENSON-TAYLOR
Suffix:
Gender:F
Credentials:AA, BA
Other - Prefix:
Other - First Name:KESSA
Other - Middle Name:MYSTIQUE
Other - Last Name:SHATTUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA, BA
Mailing Address - Street 1:245 CALVIN RD
Mailing Address - Street 2:
Mailing Address - City:CINEBAR
Mailing Address - State:WA
Mailing Address - Zip Code:98533-9700
Mailing Address - Country:US
Mailing Address - Phone:360-520-6529
Mailing Address - Fax:
Practice Address - Street 1:1430 16TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2901
Practice Address - Country:US
Practice Address - Phone:360-799-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health