Healthcare Provider Details

I. General information

NPI: 1306630827
Provider Name (Legal Business Name): STEPHENIE L RUVALCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2413 BURCHAM ST
KELSO WA
98626-5140
US

IV. Provider business mailing address

2413 BURCHAM ST
KELSO WA
98626-5140
US

V. Phone/Fax

Practice location:
  • Phone: 360-977-3558
  • Fax:
Mailing address:
  • Phone: 360-977-3558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number605572988-001-0001
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number605572988-001-0001
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: