Provider Demographics
NPI:1568520104
Name:ANDERSON, STEPHANIE RACHEL (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:RACHEL
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:RACHEL
Other - Last Name:GRIFFITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1703 COUNTRY CLUB RD STE 204
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6006
Mailing Address - Country:US
Mailing Address - Phone:910-347-3010
Mailing Address - Fax:
Practice Address - Street 1:1703 COUNTRY CLUB RD STE 204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6006
Practice Address - Country:US
Practice Address - Phone:910-347-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0047761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2851237Medicare ID - Type Unspecified