Provider Demographics
NPI:1275545527
Name:FORNESS, STEPHANIE RAE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:RAE
Last Name:FORNESS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:RAE
Other - Last Name:FABER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:408 S WHITNEY ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1212 E COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2010
Practice Address - Country:US
Practice Address - Phone:507-532-3236
Practice Address - Fax:507-532-0240
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP-4345103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41552OtherSIOUX VALLEY HEALTH
MN1043064OtherPREFERRED ONE
MN136319OtherUCARE
MN948S3FOOtherBLUE CROSS BLUE SHIELD
MNHP49480OtherHEALTH PARTNERS