Provider Demographics
NPI:1376300178
Name:VAN SWOL, STEPHANIE J
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:VAN SWOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 GOOLD ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4559
Mailing Address - Country:US
Mailing Address - Phone:262-902-1347
Mailing Address - Fax:
Practice Address - Street 1:4359 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-5056
Practice Address - Country:US
Practice Address - Phone:262-902-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1204-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst