Provider Demographics
NPI:1992373708
Name:NOVAK, STEPHANIE ANN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:NOVAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2057 W ROSCOE ST # 1REAR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6294
Mailing Address - Country:US
Mailing Address - Phone:703-969-7162
Mailing Address - Fax:
Practice Address - Street 1:2057 W ROSCOE ST # 1REAR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6294
Practice Address - Country:US
Practice Address - Phone:703-969-7162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178016844101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional