Provider Demographics
NPI:1154715597
Name:LARSEN, STEPHANIE
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MAZZANTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6233 BANKERS RD SUITE 6
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASAMT
Mailing Address - State:WI
Mailing Address - Zip Code:53403
Mailing Address - Country:US
Mailing Address - Phone:312-608-0097
Mailing Address - Fax:
Practice Address - Street 1:6233 BANKERS RD SUITE 6
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASAMT
Practice Address - State:WI
Practice Address - Zip Code:53403
Practice Address - Country:US
Practice Address - Phone:312-608-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health