Provider Demographics
NPI:1578066544
Name:STEPHANOFF, KERI (LCSW, LCPC, LBA)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:STEPHANOFF
Suffix:
Gender:F
Credentials:LCSW, LCPC, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116082 FLEECER RD
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59750-9710
Mailing Address - Country:US
Mailing Address - Phone:406-221-6273
Mailing Address - Fax:
Practice Address - Street 1:5915 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-7402
Practice Address - Country:US
Practice Address - Phone:406-221-6273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-34703101YP2500X
MT1-21-48155103K00000X
MTBBH-LCSW-LIC-388821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst