Provider Demographics
NPI:1396595302
Name:IMMERFALL, STEFFAN
Entity type:Individual
Prefix:
First Name:STEFFAN
Middle Name:
Last Name:IMMERFALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3832
Mailing Address - Country:US
Mailing Address - Phone:218-349-6434
Mailing Address - Fax:
Practice Address - Street 1:927 TRETTEL LN
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1345
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4264101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health