Basic Information
| Provider Information | |||||||||
| NPI: | 1962803122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERNESTUS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 UNION PARK ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4245434573 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 320 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NORTH EASTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023573247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4244534573 | ||||||||
| FaxNumber: | 6143559589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2014 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 11613 | MA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 29122 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 390200000X | OH | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |