Provider Demographics
NPI:1194253492
Name:WAMBOLD, STEPHANIE ANNE (MSW)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANNE
Last Name:WAMBOLD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANNE
Other - Last Name:CERQUA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:4302 UNDERHILL DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48506
Practice Address - Country:US
Practice Address - Phone:734-998-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010939391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical