Provider Demographics
NPI:1891315362
Name:STEPHENS, CHRISTLE MARIE (CDCA)
Entity Type:Individual
Prefix:
First Name:CHRISTLE
Middle Name:MARIE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 MARKET ST W
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-1019
Mailing Address - Country:US
Mailing Address - Phone:330-439-9329
Mailing Address - Fax:
Practice Address - Street 1:718 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1041
Practice Address - Country:US
Practice Address - Phone:330-615-7355
Practice Address - Fax:734-758-0784
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.175400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0416427Medicaid