Provider Demographics
NPI:1255536199
Name:MOONEY, STEPHANIE LOUISE (CDP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LOUISE
Last Name:MOONEY
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 BASSWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3672
Mailing Address - Country:US
Mailing Address - Phone:509-942-1176
Mailing Address - Fax:
Practice Address - Street 1:614 BASSWOOD AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3672
Practice Address - Country:US
Practice Address - Phone:509-942-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001109101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)