Provider Demographics
NPI:1619743036
Name:STEFENSON, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:STEFENSON
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 1:1106 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-4034
Mailing Address - Country:US
Mailing Address - Phone:917-817-4377
Mailing Address - Fax:
Practice Address - Street 1:1106 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-4034
Practice Address - Country:US
Practice Address - Phone:917-817-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013053101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional