Provider Demographics
NPI:1073919684
Name:MCMACKIN, STEPHANIE ANN (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:MCMACKIN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 E LINCOLNWAY STE G
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5671
Mailing Address - Country:US
Mailing Address - Phone:307-514-1288
Mailing Address - Fax:307-514-0979
Practice Address - Street 1:2617 E LINCOLNWAY STE G
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5671
Practice Address - Country:US
Practice Address - Phone:307-514-1288
Practice Address - Fax:307-514-0979
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
WY7301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251C00000XAgenciesDay Training, Developmentally Disabled Services