Provider Demographics
NPI:1245563014
Name:VONDEREMBSE, STEPHANIE (BA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:VONDEREMBSE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 W SCHROCK RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2890
Mailing Address - Country:US
Mailing Address - Phone:614-355-8315
Mailing Address - Fax:614-355-8361
Practice Address - Street 1:187 W SCHROCK RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2890
Practice Address - Country:US
Practice Address - Phone:614-355-8315
Practice Address - Fax:614-355-8361
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH00421103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid