Provider Demographics
NPI:1710010293
Name:HAVERSTOCK, STEPHANIE ANN (MA, LPC, NBCC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANN
Last Name:HAVERSTOCK
Suffix:
Gender:F
Credentials:MA, LPC, NBCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14316 HEATHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9124
Mailing Address - Country:US
Mailing Address - Phone:708-301-0396
Mailing Address - Fax:815-722-4390
Practice Address - Street 1:62 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-4331
Practice Address - Country:US
Practice Address - Phone:815-722-4384
Practice Address - Fax:815-722-4390
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5141Medicaid