Provider Demographics
NPI:1861280745
Name:STEPHANIE KINNARE PHD LLC
Entity type:Organization
Organization Name:STEPHANIE KINNARE PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNARE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:574-904-5200
Mailing Address - Street 1:12724 GRAN BAY PKWY W STE 410
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-9486
Mailing Address - Country:US
Mailing Address - Phone:904-574-5200
Mailing Address - Fax:
Practice Address - Street 1:12724 GRAN BAY PKWY W STE 410
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9486
Practice Address - Country:US
Practice Address - Phone:904-574-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty