Healthcare Provider Details

I. General information

NPI: 1407247257
Provider Name (Legal Business Name): STEPHANIE LOCUS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2015
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 LAKE OTIS PKWY
ANCHORAGE AK
99508-5227
US

IV. Provider business mailing address

210 SPRUCEPINE DR
RAEFORD NC
28376-8454
US

V. Phone/Fax

Practice location:
  • Phone: 907-762-8654
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP008429
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: