Provider Demographics
NPI:1548411754
Name:VANDALL, STEPHANIE DENISE (LISW-S, LICDC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DENISE
Last Name:VANDALL
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:DENISE
Other - Last Name:KOSTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:1105 SCHROCK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1174
Mailing Address - Country:US
Mailing Address - Phone:614-987-5620
Mailing Address - Fax:
Practice Address - Street 1:750 E LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1846
Practice Address - Country:US
Practice Address - Phone:614-340-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0800340104100000X
OHS0800340104100000X
OHI10002021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker