Basic Information
| Provider Information | |||||||||
| NPI: | 1649526377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YEAMAN | ||||||||
| FirstName: | STEFANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4650 HAWTHORNE RD | ||||||||
| Address2: | STE 3B | ||||||||
| City: | CHUBBUCK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082379833 | ||||||||
| FaxNumber: | 2082371800 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 HAWTHORNE RD | ||||||||
| Address2: | STE 3B | ||||||||
| City: | CHUBBUCK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082379833 | ||||||||
| FaxNumber: | 2082371800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | SE-202660 | ID | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.