1194253492 NPI number — MRS. STEPHANIE ANNE WAMBOLD MSW

Table of content: MRS. STEPHANIE ANNE WAMBOLD MSW (NPI 1194253492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194253492 NPI number — MRS. STEPHANIE ANNE WAMBOLD MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAMBOLD
Provider First Name:
STEPHANIE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CERQUA
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194253492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 S STATE ST
Provider Second Line Business Mailing Address:
700 KMS PLACE
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-936-2047
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4302 UNDERHILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-998-2163
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801093939 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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