Provider Demographics
NPI:1174794291
Name:WILLNER, STEPHANIE (CAC II)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:WILLNER
Suffix:
Gender:F
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4723
Mailing Address - Country:US
Mailing Address - Phone:918-431-0418
Mailing Address - Fax:
Practice Address - Street 1:109 W 2ND ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4723
Practice Address - Country:US
Practice Address - Phone:918-431-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1800101YA0400X
OKRECIPROCITY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)