Provider Demographics
NPI:1477243947
Name:STELLWAG, DESERAE
Entity Type:Individual
Prefix:
First Name:DESERAE
Middle Name:
Last Name:STELLWAG
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:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:TATITLEK
Mailing Address - State:AK
Mailing Address - Zip Code:99677-0172
Mailing Address - Country:US
Mailing Address - Phone:907-325-2235
Mailing Address - Fax:
Practice Address - Street 1:505 COPPER MOUNTAIN STREET
Practice Address - Street 2:
Practice Address - City:TATITLEK
Practice Address - State:AK
Practice Address - Zip Code:99677
Practice Address - Country:US
Practice Address - Phone:907-325-2235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor