Provider Demographics
NPI:1356900799
Name:PROUTY, STEPHANIE (BCABA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PROUTY
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 FARRCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6874
Mailing Address - Country:US
Mailing Address - Phone:757-404-8675
Mailing Address - Fax:
Practice Address - Street 1:9720 CAPITAL CT STE 404
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-2052
Practice Address - Country:US
Practice Address - Phone:855-910-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA0134000379103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0134000379Medicaid