Provider Demographics
NPI:1609178078
Name:KING, STEPHANIE A (BCBA, LPC-IT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:KING
Suffix:
Gender:F
Credentials:BCBA, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 N 124TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2125
Mailing Address - Country:US
Mailing Address - Phone:414-476-9755
Mailing Address - Fax:414-476-3413
Practice Address - Street 1:3636 N 124TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2125
Practice Address - Country:US
Practice Address - Phone:414-476-9755
Practice Address - Fax:414-476-3413
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI88-140103K00000X
WI1796-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional