Provider Demographics
NPI:1144801796
Name:STAMBAUGH, VIVIAN
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:STAMBAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 E STATE ROAD 14
Mailing Address - Street 2:
Mailing Address - City:SILVER LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46982-8817
Mailing Address - Country:US
Mailing Address - Phone:260-557-3805
Mailing Address - Fax:
Practice Address - Street 1:2345 E STATE ROAD 14
Practice Address - Street 2:
Practice Address - City:SILVER LAKE
Practice Address - State:IN
Practice Address - Zip Code:46982-8817
Practice Address - Country:US
Practice Address - Phone:260-839-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor