1578308458 NPI number — STEPHANIE JORDAN BECKER MSW, LICSW, LCSW

Table of content: STEPHANIE JORDAN BECKER MSW, LICSW, LCSW (NPI 1578308458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578308458 NPI number — STEPHANIE JORDAN BECKER MSW, LICSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BECKER
Provider First Name:
STEPHANIE
Provider Middle Name:
JORDAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578308458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4240 PARK GLEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-5427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-925-6033
Provider Business Mailing Address Fax Number:
612-925-8496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 HANLEY RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54016-8786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-954-5300
Provider Business Practice Location Address Fax Number:
715-954-5301
Provider Enumeration Date:
07/01/2024

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:  11812-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 25302 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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