Provider Demographics
NPI:1962024984
Name:TRUDEAUX, STEPHANIE ANN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:TRUDEAUX
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 1:123 LINDA CT
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3422
Mailing Address - Country:US
Mailing Address - Phone:970-759-5562
Mailing Address - Fax:
Practice Address - Street 1:123 LINDA CT
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-3422
Practice Address - Country:US
Practice Address - Phone:970-759-5562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO183840101YS0200X
CO0006070101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty