Provider Demographics
NPI:1083003339
Name:AEGISDOTTIR, STEFANIA (PHD)
Entity Type:Individual
Prefix:
First Name:STEFANIA
Middle Name:
Last Name:AEGISDOTTIR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 N BRIARWOOD LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5214
Mailing Address - Country:US
Mailing Address - Phone:765-289-5520
Mailing Address - Fax:
Practice Address - Street 1:3645 N BRIARWOOD LN
Practice Address - Street 2:SUITE A
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5214
Practice Address - Country:US
Practice Address - Phone:765-289-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042122A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling