Provider Demographics
NPI:1437284759
Name:RAY, STEPHANIE R (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:RAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:RICHE-WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:900 E LAHARPE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4520
Mailing Address - Country:US
Mailing Address - Phone:660-665-1962
Mailing Address - Fax:
Practice Address - Street 1:3510 FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2987
Practice Address - Country:US
Practice Address - Phone:816-364-6007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001522331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical