Provider Demographics
NPI:1578619359
Name:FIDLER, STEPHANIE ANGELLA (PSY D)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANGELLA
Last Name:FIDLER
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 M 291 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057
Mailing Address - Country:US
Mailing Address - Phone:816-373-9240
Mailing Address - Fax:816-373-9243
Practice Address - Street 1:3031 M 291 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2334
Practice Address - Country:US
Practice Address - Phone:816-373-9240
Practice Address - Fax:816-373-9243
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004000217103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical