Provider Demographics
NPI:1568660249
Name:STUCKERT, STEPHANIE JANE (BS)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JANE
Last Name:STUCKERT
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MANTOOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:198 E ALMAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018
Mailing Address - Country:US
Mailing Address - Phone:405-222-5437
Mailing Address - Fax:
Practice Address - Street 1:6100 S WALKER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-7026
Practice Address - Country:US
Practice Address - Phone:405-634-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4SJM71OtherICIS