MEDICARE: MRS. STEPHANIE MICHELLE STIDHAM LCSW

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	1041C0700X	Clinical Social Worker	LCS23247	CA
2	1041C0700X	Clinical Social Worker	LCSW64567	TX

General Provider Information

NPI Number	:	1811514821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE MICHELLE STIDHAM LCSW

Provider Business Mailing Address
First Line	:	3308 PABLO CIR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-2160
Country	:	US
Telephone Number	:	949-973-7419
Fax Number	:

Provider Business Practice Location Address
First Line	:	3308 PABLO CIR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-2160
Country	:	US
Telephone Number	:	949-973-7419
Fax Number	:

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

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	06/25/2020

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