Provider Demographics
NPI:1003655705
Name:MCCOY, STEPHANIE RENEE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:MCCOY
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 1:200 MARRIOTT DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 E CONCHO ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-4116
Practice Address - Country:US
Practice Address - Phone:361-727-0988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX88737101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health