Provider Demographics
NPI:1265561708
Name:DETHY, STEPHANIE JO
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JO
Last Name:DETHY
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 1:11523 VALLEY FRG
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-8403
Mailing Address - Country:US
Mailing Address - Phone:502-931-7111
Mailing Address - Fax:866-528-4353
Practice Address - Street 1:11523 VALLEY FRG
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-8403
Practice Address - Country:US
Practice Address - Phone:502-931-7111
Practice Address - Fax:866-528-4353
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN958866174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200825930OtherFIRST STEPS PROVIDER NUMB
IN958866OtherTEACHER'S LICENSE