MEDICARE: TENNILLE STANFIELD MS,LPC-IT,NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	7971-226	WI

General Provider Information

NPI Number	:	1245075068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TENNILLE STANFIELD MS,LPC-IT,NCC

Provider Business Mailing Address
First Line	:	4305 OLD GREEN BAY RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9425
Country	:	US
Telephone Number	:	262-221-8152
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 OLD GREEN BAY RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9425
Country	:	US
Telephone Number	:	262-822-8152
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2024
Last Update Date	:	06/25/2024

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