Provider Demographics
NPI:1104214386
Name:EWOLDT, STEPHANIE ANN (LIMHP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:EWOLDT
Suffix:
Gender:F
Credentials:LIMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 S. 40TH ST. #300
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-5248
Mailing Address - Country:US
Mailing Address - Phone:402-413-1751
Mailing Address - Fax:833-831-9280
Practice Address - Street 1:1919 S 40TH ST STE 300
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5248
Practice Address - Country:US
Practice Address - Phone:402-413-1751
Practice Address - Fax:833-831-9280
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1852101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE823345751OtherNA