Provider Demographics
NPI:1871066555
Name:IDALSKI, STEPHANIE (LPCM)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:IDALSKI
Suffix:
Gender:F
Credentials:LPCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1846
Mailing Address - Country:US
Mailing Address - Phone:989-255-4508
Mailing Address - Fax:
Practice Address - Street 1:140 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1846
Practice Address - Country:US
Practice Address - Phone:989-255-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-06
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1760101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional