Basic Information
Provider Information | |||||||||
NPI: | 1710166350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STACKENWALT | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MHR, LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ALLEMAN | ||||||||
OtherFirstName: | STEPHANIE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4436 NW 50TH ST | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731122212 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058582821 | ||||||||
FaxNumber: | 4058582810 | ||||||||
Practice Location | |||||||||
Address1: | 2322 W 7TH AVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | STILLWATER | ||||||||
State: | OK | ||||||||
PostalCode: | 740741903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057079722 | ||||||||
FaxNumber: | 4057070662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2007 | ||||||||
LastUpdateDate: | 10/31/2007 | ||||||||
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 | 101YM0800X | 3284 | OK | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 3284 | 01 | OK | COUNSELOR-MENTAL HEALTH | OTHER |