Provider Demographics
NPI:1801584586
Name:STEPHENS, QUENYETTA OLIVIA
Entity type:Individual
Prefix:
First Name:QUENYETTA
Middle Name:OLIVIA
Last Name:STEPHENS
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:PO BOX 290851
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33687-0851
Mailing Address - Country:US
Mailing Address - Phone:813-778-9808
Mailing Address - Fax:
Practice Address - Street 1:5902 TERRACE SQUARE DR APT D
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-1311
Practice Address - Country:US
Practice Address - Phone:813-778-9808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician