Provider Demographics
NPI:1053673582
Name:WOGOMON, STEPHANIE MARIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:WOGOMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:ACOSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10439 S 51ST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5224
Mailing Address - Country:US
Mailing Address - Phone:909-395-6602
Mailing Address - Fax:
Practice Address - Street 1:10439 S 51ST ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-5224
Practice Address - Country:US
Practice Address - Phone:480-635-9944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ222111041C0700X
CA1007991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical