Basic Information
| Provider Information | |||||||||
| NPI: | 1578297222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WACKER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 N MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449021042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043092941 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2022 | ||||||||
| LastUpdateDate: | 07/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | S.2207938 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.