Healthcare Provider Details

I. General information

NPI: 1700236718
Provider Name (Legal Business Name): STEPHANIE MOKRY B.S. CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE MUTCH B.S.

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 NORTHWEST BLVD SUITE C
COEUR D ALENE ID
83814-2114
US

IV. Provider business mailing address

1044 NORTHWEST BLVD SUITE C
COEUR D ALENE ID
83814-2114
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-7777
  • Fax: 208-667-7772
Mailing address:
  • Phone: 208-667-7777
  • Fax: 208-667-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberIBADDCC/CADC #10310
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: