Provider Demographics
NPI:1013659614
Name:PHELPS, STEPHANIE LEEANNE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEEANNE
Last Name:PHELPS
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 1:2118 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1320
Mailing Address - Country:US
Mailing Address - Phone:910-303-8161
Mailing Address - Fax:
Practice Address - Street 1:1776 HERITAGE DR. STE 204
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3977
Practice Address - Country:US
Practice Address - Phone:919-971-8744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12354A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist