Provider Demographics
NPI:1851066591
Name:ANDERSON, STEPHANIE J
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:J
Last Name:ANDERSON
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 1:1163 N 164TH AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-6296
Mailing Address - Country:US
Mailing Address - Phone:623-206-2212
Mailing Address - Fax:
Practice Address - Street 1:1163 N 164TH AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6296
Practice Address - Country:US
Practice Address - Phone:623-206-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ01OtherBEHAVIORAL COACH