Provider Demographics
NPI:1497005169
Name:CAMACHO, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CAMACHO
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 1:4404 N LIBBY AVE
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73122-4405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1390 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5270
Practice Address - Country:US
Practice Address - Phone:405-455-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health