Provider Demographics
NPI:1619455813
Name:ANDERSON, STEFANI (BS)
Entity Type:Individual
Prefix:
First Name:STEFANI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:STEFANI
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 BROADWAY AVE E
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 W CLARK ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4637
Practice Address - Country:US
Practice Address - Phone:217-398-9066
Practice Address - Fax:217-398-9077
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health