Provider Demographics
NPI:1417720392
Name:MCCOMB, STEFANI
Entity Type:Individual
Prefix:
First Name:STEFANI
Middle Name:
Last Name:MCCOMB
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 1:110 W BROADWAY STE 202
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-6056
Mailing Address - Country:US
Mailing Address - Phone:701-774-6300
Mailing Address - Fax:
Practice Address - Street 1:110 W BROADWAY STE 202
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6056
Practice Address - Country:US
Practice Address - Phone:701-774-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker