Provider Demographics
NPI:1477745446
Name:BLACK, STEPHANIE BROADBENT (LCSW, LISW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BROADBENT
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW, LISW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:PATRICE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:533 N 450 E
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-3402
Mailing Address - Country:US
Mailing Address - Phone:319-621-9581
Mailing Address - Fax:
Practice Address - Street 1:2319 CATSKILL CT
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245-5250
Practice Address - Country:US
Practice Address - Phone:319-621-9581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6656502-35021041C0700X
UT6656502-35011041C0700X
IA0080911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical