Provider Demographics
NPI:1801397138
Name:KAMP, STEPHANIE L
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:KAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 BRINKERHOFF AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3208
Mailing Address - Country:US
Mailing Address - Phone:330-926-7351
Mailing Address - Fax:
Practice Address - Street 1:111 BRINKERHOFF AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3208
Practice Address - Country:US
Practice Address - Phone:330-926-7351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2023-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS0021373OtherOHIO PROFESSIONAL LICENSURE