Provider Demographics
NPI:1841871381
Name:LOERA, STEPHANIE WIDACKI (RBT)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:WIDACKI
Last Name:LOERA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:WIDACKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9901 N CAPITAL OF TEXAS HWY STE 250
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5977
Mailing Address - Country:US
Mailing Address - Phone:512-887-2126
Mailing Address - Fax:
Practice Address - Street 1:9901 N CAPITAL OF TEXAS HWY STE 250
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5977
Practice Address - Country:US
Practice Address - Phone:512-887-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-19-91465106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-19-915465OtherBACB CERTIFICATION NUMBER