Provider Demographics
NPI:1609383736
Name:GIMENEZ, STEPHANIE (NCC, LPCA, LCAS-A)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GIMENEZ
Suffix:
Gender:F
Credentials:NCC, LPCA, LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 STRATFORD CT STE 225
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1836
Mailing Address - Country:US
Mailing Address - Phone:336-986-2720
Mailing Address - Fax:
Practice Address - Street 1:163 STRATFORD CT STE 225
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1836
Practice Address - Country:US
Practice Address - Phone:336-986-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24441101YA0400X
NCA13588101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional