Healthcare Provider Details

I. General information

NPI: 1437405313
Provider Name (Legal Business Name): STEFANIE GREENBERG MOKHTARIAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-5711
  • Fax: 812-855-8447
Mailing address:
  • Phone: 812-855-5711
  • Fax: 812-855-8447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20042590A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: