Provider Demographics
NPI:1518700905
Name:VAN NUFFELEN, STEPHANIE RENEE (BCBA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:VAN NUFFELEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1830
Mailing Address - Country:US
Mailing Address - Phone:815-370-2988
Mailing Address - Fax:
Practice Address - Street 1:777 JOYCE RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-1876
Practice Address - Country:US
Practice Address - Phone:815-823-8214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-24-72753103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst