Healthcare Provider Details

I. General information

NPI: 1710167374
Provider Name (Legal Business Name): RABECCA KATHRYN STAHL STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2007
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 COTTONROSE DR
DAYTON OH
45431-1579
US

IV. Provider business mailing address

5555 COTTONROSE DR
DAYTON OH
45431-1579
US

V. Phone/Fax

Practice location:
  • Phone: 502-377-3555
  • Fax:
Mailing address:
  • Phone: 502-377-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: