Healthcare Provider Details

I. General information

NPI: 1023148111
Provider Name (Legal Business Name): STEPHANIE LEA PAVOLKO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 LAKE AVE
ASHTABULA OH
44004-4954
US

IV. Provider business mailing address

10 JULIET ST
ALBION PA
16401-1012
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-6641
  • Fax:
Mailing address:
  • Phone: 814-756-0474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS0600581
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: