Provider Demographics
NPI:1104406875
Name:CUMMINGS, STEPHANIE ANNE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:CUMMINGS
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 1:1319 NE BARNEY ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-2013
Mailing Address - Country:US
Mailing Address - Phone:971-275-5083
Mailing Address - Fax:
Practice Address - Street 1:357 NE COURT ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1936
Practice Address - Country:US
Practice Address - Phone:971-275-5083
Practice Address - Fax:541-504-7535
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-21-746101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)