Provider Demographics
NPI:1891753125
Name:ANDERSON, STEPHEN L (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 S 20TH ST
Mailing Address - Street 2:SUITE 219
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3732
Mailing Address - Country:US
Mailing Address - Phone:414-897-5511
Mailing Address - Fax:414-385-7552
Practice Address - Street 1:1032 S 16TH ST
Practice Address - Street 2:SUITE 219
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204
Practice Address - Country:US
Practice Address - Phone:414-672-3145
Practice Address - Fax:414-383-5597
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9761231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39586600Medicaid
R97893Medicare UPIN
WI084994004Medicare ID - Type Unspecified