Basic Information
| Provider Information | |||||||||
| NPI: | 1467578088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLYNN | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDINGTON | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 925 STATE ROUTE VV, PO BOX 71 | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738885925 | ||||||||
| FaxNumber: | 8709724911 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 STATE ROUTE VV | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738885925 | ||||||||
| FaxNumber: | 8709724911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 03/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4995-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.