Provider Demographics
NPI:1427820166
Name:KINZIE, STEFANIE RAE
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:RAE
Last Name:KINZIE
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 1:5636 S MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-9025
Mailing Address - Country:US
Mailing Address - Phone:540-230-6212
Mailing Address - Fax:
Practice Address - Street 1:3208 HERSHBERGER RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-1842
Practice Address - Country:US
Practice Address - Phone:540-227-8426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)