Provider Demographics
NPI:1073341137
Name:GEORGE, STEPHANIE DIANE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ROCKLICK BRANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-7647
Mailing Address - Country:US
Mailing Address - Phone:304-784-8709
Mailing Address - Fax:304-855-8709
Practice Address - Street 1:110 ROCKLICK BRANCH ROAD
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508-7647
Practice Address - Country:US
Practice Address - Phone:304-784-8709
Practice Address - Fax:304-855-8709
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVE616032252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency