Provider Demographics
NPI:1992238802
Name:STREET, STEPHANIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:SIMONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:400 COLUMBUS AVE
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1233
Mailing Address - Country:US
Mailing Address - Phone:203-503-3174
Mailing Address - Fax:203-503-3183
Practice Address - Street 1:226 DIXWELL AVE
Practice Address - Street 2:NORTHSIDE COMMUNITY OUTPATIENT SERVICES
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3456
Practice Address - Country:US
Practice Address - Phone:203-503-3470
Practice Address - Fax:203-503-3478
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT96501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008071422Medicaid
CT9650OtherLCSW LICENSE