Basic Information
| Provider Information | |||||||||
| NPI: | 1356334106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANGE | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 14TH ST | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612016034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092357644 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ROCK ISLAND ARSENAL HEALTH CLINIC, (RIAHC) | ||||||||
| Address2: | ATTN: MCXM-DMC, BUILDING 110 | ||||||||
| City: | ROCK ISLAND ARSENAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612997240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097820805 | ||||||||
| FaxNumber: | 3097820810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149006942 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 149006942 | 01 | IL | BLUE CROSS ILLINOIS NUMBE | OTHER | JB420B1 | 01 | IL | JOHN DEERE PROVIDER NUMB | OTHER | 99254 | 01 | IL | BLUE CROSS IOWA | OTHER |