Healthcare Provider Details

I. General information

NPI: 1043056054
Provider Name (Legal Business Name): STEPHANIE WYSONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 CLIFFSIDE CT
LAFAYETTE IN
47905-8567
US

IV. Provider business mailing address

733 CLIFFSIDE CT
LAFAYETTE IN
47905-8567
US

V. Phone/Fax

Practice location:
  • Phone: 317-409-5665
  • Fax:
Mailing address:
  • Phone: 317-409-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: