Provider Demographics
NPI:1679229918
Name:STEPHAN, KERIANNE CHRISTINE
Entity Type:Individual
Prefix:
First Name:KERIANNE
Middle Name:CHRISTINE
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 N WINTHROP AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4355
Mailing Address - Country:US
Mailing Address - Phone:949-351-6783
Mailing Address - Fax:
Practice Address - Street 1:5700 N WINTHROP AVE APT 6
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4355
Practice Address - Country:US
Practice Address - Phone:949-351-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-11-22
Deactivation Date:2022-04-12
Deactivation Code:
Reactivation Date:2022-11-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling