Provider Demographics
NPI:1578078549
Name:PROFERA, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PROFERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44003-9318
Mailing Address - Country:US
Mailing Address - Phone:440-563-6524
Mailing Address - Fax:330-369-1595
Practice Address - Street 1:158 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:OH
Practice Address - Zip Code:44003-9318
Practice Address - Country:US
Practice Address - Phone:440-563-6524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2105847104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker