Provider Demographics
NPI:1861849507
Name:ZIMMERMAN-CHILDRESS, STEPHANIE (301385)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ZIMMERMAN-CHILDRESS
Suffix:
Gender:F
Credentials:301385
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3428 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4529
Mailing Address - Country:US
Mailing Address - Phone:612-250-5936
Mailing Address - Fax:
Practice Address - Street 1:3428 5TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4529
Practice Address - Country:US
Practice Address - Phone:612-250-5936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301385101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)