Provider Demographics
NPI:1003173063
Name:WRIGHT, STEPHANIE BERG (MS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BERG
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1867
Mailing Address - Fax:947-522-0301
Practice Address - Street 1:30503 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1594
Practice Address - Country:US
Practice Address - Phone:248-691-4744
Practice Address - Fax:248-691-4745
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011218101YP2500X
MI6301014114103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401011218OtherSTATE LICENSE
MI6301014114OtherSTATE LICENSE NUMBER