Basic Information
| Provider Information | |||||||||
| NPI: | 1851953178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANON | ||||||||
| FirstName: | STEFANIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319075609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006765130 | ||||||||
| FaxNumber: | 8889595753 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319075609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006765130 | ||||||||
| FaxNumber: | 8889595753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2019 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-19-91375 | 01 | BEHAVIORAL THERAPY | OTHER |