Provider Demographics
NPI:1265029904
Name:MADRIZ, STEPHANIE KETZIA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KETZIA
Last Name:MADRIZ
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 1:932 S 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5719
Mailing Address - Country:US
Mailing Address - Phone:509-492-1625
Mailing Address - Fax:
Practice Address - Street 1:1950 KEENE RD BLDG K
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-7752
Practice Address - Country:US
Practice Address - Phone:509-420-3442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty