Provider Demographics
NPI:1528388170
Name:MOONINGHAM, STEPHANIE
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:MOONINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:CLEMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5501 N 19TH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2450
Mailing Address - Country:US
Mailing Address - Phone:602-433-1344
Mailing Address - Fax:
Practice Address - Street 1:7865 W BOCA RATON RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4687
Practice Address - Country:US
Practice Address - Phone:623-979-4406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-06
Last Update Date:2010-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1619104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker