Basic Information
| Provider Information | |||||||||
| NPI: | 1174999460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YANCEY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAUER | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 482 BLACK RIVER PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157821777 | ||||||||
| FaxNumber: | 3157858628 | ||||||||
| Practice Location | |||||||||
| Address1: | 7550 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | LOWVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133671533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153765450 | ||||||||
| FaxNumber: | 3153767221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2015 | ||||||||
| LastUpdateDate: | 07/08/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 095382 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.