Provider Demographics
NPI:1811514821
Name:STIDHAM, STEPHANIE MICHELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:WILGUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3308 PABLO CIR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-2160
Mailing Address - Country:US
Mailing Address - Phone:949-973-7419
Mailing Address - Fax:
Practice Address - Street 1:3308 PABLO CIR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-2160
Practice Address - Country:US
Practice Address - Phone:949-973-7419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS232471041C0700X
TXLCSW645671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical