Provider Demographics
NPI:1417596214
Name:MARTIN, STEPHANIE SUZANNE (MAADC II, PLPC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUZANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MAADC II, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23240 REGAL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-6967
Mailing Address - Country:US
Mailing Address - Phone:417-718-7108
Mailing Address - Fax:
Practice Address - Street 1:860 LYNN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3810
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022014720101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health