Provider Demographics
NPI:1205136173
Name:KOUTSKY, STEPHANIE (MS, BCBA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KOUTSKY
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W MORSE AVE
Mailing Address - Street 2:#410
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3070
Mailing Address - Country:US
Mailing Address - Phone:773-609-4076
Mailing Address - Fax:773-345-4606
Practice Address - Street 1:1225 W MORSE AVE
Practice Address - Street 2:#410
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-3070
Practice Address - Country:US
Practice Address - Phone:773-609-4076
Practice Address - Fax:773-345-4606
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-09-5576103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst