Provider Demographics
NPI:1326473455
Name:TRAVERSIE, STEPHANIE M (MS)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:M
Last Name:TRAVERSIE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 19TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-2823
Mailing Address - Country:US
Mailing Address - Phone:605-886-0123
Mailing Address - Fax:
Practice Address - Street 1:123 19TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-2823
Practice Address - Country:US
Practice Address - Phone:605-886-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5200010Medicaid