Basic Information
| Provider Information | |||||||||
| NPI: | 1972112787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISAAK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LAPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1334 COLUMBIA DR | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585046530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7019558414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7785 SAINT GERTRUDE AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585644103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015973419 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2020 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 1079-8-1-20A | ND | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1079-8-1-20A | 05 | ND | MEDICAID |