Provider Demographics
NPI:1649772039
Name:STEPHENSON, MONIQUE RENEE'
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:RENEE'
Last Name:STEPHENSON
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 1:3105 ORIOLE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7561
Mailing Address - Country:US
Mailing Address - Phone:253-358-0466
Mailing Address - Fax:
Practice Address - Street 1:1325 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1416
Practice Address - Country:US
Practice Address - Phone:541-942-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health