Provider Demographics
NPI:1558629006
Name:SIFUENTES, STEPHANIE M (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:SIFUENTES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:BLAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-804-3109
Mailing Address - Fax:512-472-4008
Practice Address - Street 1:1717 W 10TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-3907
Practice Address - Country:US
Practice Address - Phone:512-804-3109
Practice Address - Fax:512-472-4008
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX524031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical