Healthcare Provider Details

I. General information

NPI: 1649526377
Provider Name (Legal Business Name): STEFANE YEAMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HAWTHORNE RD STE 3B
CHUBBUCK ID
83202-2376
US

IV. Provider business mailing address

4650 HAWTHORNE RD STE 3B
CHUBBUCK ID
83202-2376
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-9833
  • Fax: 208-237-1800
Mailing address:
  • Phone: 208-237-9833
  • Fax: 208-237-1800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberSE-202660
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: