Provider Demographics
NPI:1780915124
Name:ETIE, STEPHANIE ANN (M ED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:ETIE
Suffix:
Gender:F
Credentials:M ED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90851
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78709-0851
Mailing Address - Country:US
Mailing Address - Phone:512-423-4467
Mailing Address - Fax:512-892-1422
Practice Address - Street 1:5924 RICKERHILL LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78739
Practice Address - Country:US
Practice Address - Phone:512-423-4467
Practice Address - Fax:512-892-1422
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX350103K00000X
TX1-06-3148103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty