Provider Demographics
NPI:1942854732
Name:RUTHERFORD, STEPHANIE LYNN (LMSW-CLINICAL)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:LMSW-CLINICAL
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1651 E NICKERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-2469
Mailing Address - Country:US
Mailing Address - Phone:269-983-5833
Mailing Address - Fax:
Practice Address - Street 1:1651 E NICKERSON AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-2469
Practice Address - Country:US
Practice Address - Phone:269-983-5833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011113431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical