Provider Demographics
NPI:1326501396
Name:CHERRY, STEPHANIE ALYSE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ALYSE
Last Name:CHERRY
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 RENFRO ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-4706
Mailing Address - Country:US
Mailing Address - Phone:817-675-2088
Mailing Address - Fax:
Practice Address - Street 1:911 N GOLIAD ST
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-2230
Practice Address - Country:US
Practice Address - Phone:817-675-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80368101YP2500X
TX1-19-35317103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional