Healthcare Provider Details

I. General information

NPI: 1043718133
Provider Name (Legal Business Name): STEPHANIE KNOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4632 NE STALLINGS DR STE 100
NACOGDOCHES TX
75965-1621
US

IV. Provider business mailing address

2001 S MEDFORD DR
LUFKIN TX
75901-6260
US

V. Phone/Fax

Practice location:
  • Phone: 936-569-6849
  • Fax:
Mailing address:
  • Phone: 936-633-5672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number74927
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: