Provider Demographics
NPI:1114711165
Name:PROVIS, STEPHANIE LYNN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:PROVIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 W LINCOLN HWY APT 3107
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2932
Mailing Address - Country:US
Mailing Address - Phone:815-901-7781
Mailing Address - Fax:
Practice Address - Street 1:34 W GRAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1224
Practice Address - Country:US
Practice Address - Phone:847-322-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health