Provider Demographics
NPI:1578297222
Name:WACKER, STEPHANIE MARIE (LSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:WACKER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902-1042
Mailing Address - Country:US
Mailing Address - Phone:904-309-2941
Mailing Address - Fax:
Practice Address - Street 1:151 MARION AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2223
Practice Address - Country:US
Practice Address - Phone:419-774-9969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-10
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2207938101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health