Basic Information
| Provider Information | |||||||||
| NPI: | 1184957334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE EAGLE | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MFT,CSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | S2845 WHITE EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539139064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083551240 | ||||||||
| FaxNumber: | 6083567152 | ||||||||
| Practice Location | |||||||||
| Address1: | S2845 WHITE EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539139064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083551240 | ||||||||
| FaxNumber: | 6083567152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2009 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11480-132 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | 1258-124 | WI | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1184957334 | 05 | WI | MEDICAID |