Provider Demographics
NPI:1205005634
Name:STEPHAN, INGRID J (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:J
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 LAKELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5831
Mailing Address - Country:US
Mailing Address - Phone:608-249-0374
Mailing Address - Fax:
Practice Address - Street 1:2914 LAKELAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5831
Practice Address - Country:US
Practice Address - Phone:608-249-0374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI427-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42600100Medicaid