Healthcare Provider Details

I. General information

NPI: 1467741876
Provider Name (Legal Business Name): STEPHANIE R CALATO LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE R SMITH LCPC

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 E STATE ST SUITE 130
ROCKFORD IL
61108-2100
US

IV. Provider business mailing address

3504 WIND POINT DR
ROCKFORD IL
61108-3721
US

V. Phone/Fax

Practice location:
  • Phone: 815-218-7964
  • Fax:
Mailing address:
  • Phone: 815-218-7964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180007094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: