Provider Demographics
NPI:1013616242
Name:FOOTH, STEPHANIE IRENE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:IRENE
Last Name:FOOTH
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 1:1267 11TH AVE SW APT 308
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1374
Mailing Address - Country:US
Mailing Address - Phone:763-283-7192
Mailing Address - Fax:
Practice Address - Street 1:1011 MEADOWLANDS DR STE 1
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-2340
Practice Address - Country:US
Practice Address - Phone:612-445-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician