Provider Demographics
NPI:1568517993
Name:KOUTCHER, STEPHANIE A
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:KOUTCHER
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:PO BOX 31094
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-1094
Mailing Address - Country:US
Mailing Address - Phone:518-952-8140
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:19 GREENRIDGE AVE
Practice Address - Street 2:ANDRUS CHILDREN'S CENTER
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1201
Practice Address - Country:US
Practice Address - Phone:914-949-6780
Practice Address - Fax:914-949-3525
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078977101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420795Medicaid