Provider Demographics
NPI:1881414308
Name:THACKER, STEPHANIE R (MA, LMHC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:THACKER
Suffix:
Gender:
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 E COLFAX AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617
Mailing Address - Country:US
Mailing Address - Phone:269-985-8217
Mailing Address - Fax:844-930-4791
Practice Address - Street 1:616 E COLFAX AVE
Practice Address - Street 2:STE 2
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2827
Practice Address - Country:US
Practice Address - Phone:269-985-8217
Practice Address - Fax:844-930-4791
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39005154A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health