Healthcare Provider Details

I. General information

NPI: 1801366992
Provider Name (Legal Business Name): DR. STEPHANIE CAROL SMITH KELLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S 36TH AVE
WAUSAU WI
54401-3930
US

IV. Provider business mailing address

630 S 36TH AVE
WAUSAU WI
54401-3930
US

V. Phone/Fax

Practice location:
  • Phone: 855-607-8242
  • Fax:
Mailing address:
  • Phone: 855-607-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12262
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-18-65709
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4155-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: