Healthcare Provider Details

I. General information

NPI: 1801514633
Provider Name (Legal Business Name): STEPHANIE MEPHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 W BELTLINE HWY STE 300
MADISON WI
53713-2934
US

IV. Provider business mailing address

1161 LAKE COOK RD
DEERFIELD IL
60015-5649
US

V. Phone/Fax

Practice location:
  • Phone: 224-284-2240
  • Fax: 312-893-2118
Mailing address:
  • Phone: 224-284-2240
  • Fax: 312-893-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-22-229518
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: