Provider Demographics
NPI:1184957334
Name:WHITE EAGLE, STEPHANIE LYNN (MFT,CSAC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:WHITE EAGLE
Suffix:
Gender:F
Credentials:MFT,CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S2845 WHITE EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9064
Mailing Address - Country:US
Mailing Address - Phone:608-355-1240
Mailing Address - Fax:608-356-7152
Practice Address - Street 1:S2845 WHITE EAGLE RD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9064
Practice Address - Country:US
Practice Address - Phone:608-355-1240
Practice Address - Fax:608-356-7152
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11480-132101YA0400X
WI1258-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184957334Medicaid