Healthcare Provider Details

I. General information

NPI: 1134786783
Provider Name (Legal Business Name): STACEY KERWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 11/28/2024
Certification Date: 11/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 PINTAIL DR
SPRINGFIELD IL
62711-6738
US

IV. Provider business mailing address

3921 PINTAIL DR
SPRINGFIELD IL
62711-6738
US

V. Phone/Fax

Practice location:
  • Phone: 815-216-7983
  • Fax:
Mailing address:
  • Phone: 815-216-7983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-37132
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: