Provider Demographics
NPI:1922355858
Name:BICHANICH, STEPHANIE ROSELLA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSELLA
Last Name:BICHANICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ROSELLA
Other - Last Name:DIETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 FOURIER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1969
Mailing Address - Country:US
Mailing Address - Phone:608-662-9327
Mailing Address - Fax:608-662-9041
Practice Address - Street 1:1210 FOURIER DR STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1969
Practice Address - Country:US
Practice Address - Phone:608-662-9327
Practice Address - Fax:608-662-9041
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4846-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4846-125OtherSTATE OF WI