Provider Demographics
NPI:1487160644
Name:SMITH, STEPHANIE RAE (CLC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5126 MARTHA DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-8794
Mailing Address - Country:US
Mailing Address - Phone:262-501-1359
Mailing Address - Fax:
Practice Address - Street 1:5126 MARTHA DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-8794
Practice Address - Country:US
Practice Address - Phone:262-501-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIALPP-42079101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor