Provider Demographics
NPI:1740576321
Name:WILSON, STEPHANIE E (LISW-S)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:E
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8309 TRAIL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8144
Mailing Address - Country:US
Mailing Address - Phone:704-576-8904
Mailing Address - Fax:
Practice Address - Street 1:90 S HIGH ST STE E
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-1171
Practice Address - Country:US
Practice Address - Phone:614-579-9657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1000327101YM0800X
OHI10003271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicaid