Healthcare Provider Details

I. General information

NPI: 1962024984
Provider Name (Legal Business Name): STEPHANIE ANN TRUDEAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 LINDA CT
DURANGO CO
81301-3422
US

IV. Provider business mailing address

123 LINDA CT
DURANGO CO
81301-3422
US

V. Phone/Fax

Practice location:
  • Phone: 970-759-5562
  • Fax:
Mailing address:
  • Phone: 970-759-5562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number183840
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0006070
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: