Healthcare Provider Details

I. General information

NPI: 1538476742
Provider Name (Legal Business Name): STEPHEN FRAZIER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N RUBY LN
FAIRVIEW HEIGHTS IL
62208-1926
US

IV. Provider business mailing address

125 N RUBY LN
FAIRVIEW HEIGHTS IL
62208-1926
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-4226
  • Fax: 618-398-1759
Mailing address:
  • Phone: 618-398-4226
  • Fax: 618-398-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014264
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2009028441
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: