Provider Demographics
NPI:1508607581
Name:WELLNITZ, STEPHANIE JILL
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JILL
Last Name:WELLNITZ
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 1:1903 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3628
Mailing Address - Country:US
Mailing Address - Phone:605-695-1713
Mailing Address - Fax:
Practice Address - Street 1:4342 15TH AVE S STE 105
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1125
Practice Address - Country:US
Practice Address - Phone:605-695-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician