Provider Demographics
NPI:1467888727
Name:SMITH FOSTVEDT, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SMITH FOSTVEDT
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 1:2519 N HILLCREST PARKWAY
Mailing Address - Street 2:SUITE201
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2588
Mailing Address - Country:US
Mailing Address - Phone:715-832-8432
Mailing Address - Fax:715-832-5007
Practice Address - Street 1:2519 N HILLCREST PKWY
Practice Address - Street 2:SUITE201
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2584
Practice Address - Country:US
Practice Address - Phone:715-832-8432
Practice Address - Fax:715-832-5007
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1704-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health