Healthcare Provider Details

I. General information

NPI: 1225474570
Provider Name (Legal Business Name): STEPHANY STORDAHL M.S., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANY REETZ

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 03/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CALEDONIA ST
LA CROSSE WI
54603-2616
US

IV. Provider business mailing address

1412 WOOD ST
LA CROSSE WI
54603-2403
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-4100
  • Fax:
Mailing address:
  • Phone: 715-210-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number71140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: