Provider Demographics
NPI:1487210332
Name:POWELL, STEFANIE RENAE (RBT)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:RENAE
Last Name:POWELL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:RENAE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:524 E GREENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-4118
Mailing Address - Country:US
Mailing Address - Phone:405-838-2821
Mailing Address - Fax:
Practice Address - Street 1:524 E GREENWOOD LN
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-4118
Practice Address - Country:US
Practice Address - Phone:405-838-2821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician