Provider Demographics
NPI:1295069029
Name:STUBENRAUCH, SCOTT W (PSYD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
Last Name:STUBENRAUCH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 ALANA DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1766
Mailing Address - Country:US
Mailing Address - Phone:815-462-3827
Mailing Address - Fax:
Practice Address - Street 1:339 ALANA DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1766
Practice Address - Country:US
Practice Address - Phone:815-462-3827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-26
Last Update Date:2009-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007574103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical