Healthcare Provider Details

I. General information

NPI: 1164344404
Provider Name (Legal Business Name): IVORY ROSE STEPHENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 JEFFERSON ST
MONTE VISTA CO
81144-1715
US

IV. Provider business mailing address

466 JEFFERSON ST
MONTE VISTA CO
81144-1715
US

V. Phone/Fax

Practice location:
  • Phone: 719-850-2534
  • Fax:
Mailing address:
  • Phone: 719-850-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-499170
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: