Provider Demographics
NPI:1871929349
Name:CHURCH, STEPHANIE MARIE (MS)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:ELBRECHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:934 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12303-1528
Mailing Address - Country:US
Mailing Address - Phone:607-727-7089
Mailing Address - Fax:
Practice Address - Street 1:623 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4031
Practice Address - Country:US
Practice Address - Phone:518-782-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2065497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist