Provider Demographics
NPI:1962803122
Name:ERNESTUS, STEPHANIE M (PHD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:ERNESTUS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 UNION PARK ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2498
Mailing Address - Country:US
Mailing Address - Phone:424-543-4573
Mailing Address - Fax:
Practice Address - Street 1:320 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02357-3247
Practice Address - Country:US
Practice Address - Phone:424-453-4573
Practice Address - Fax:614-355-9589
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11613103TC0700X
CA29122103TC0700X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid