Basic Information
| Provider Information | |||||||||
| NPI: | 1568603207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEFANKO | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 471 BARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066082409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033336864 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Practice Location | |||||||||
| Address1: | 1734 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035761382 | ||||||||
| FaxNumber: | 2035799519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2009 | ||||||||
| LastUpdateDate: | 03/10/2009 | ||||||||
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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 | 1041S0200X | 003405 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
| ID | Type | State | Issuer | Description | 003405 | 01 | CT | 0003405 | OTHER |