Provider Demographics
NPI:1023402781
Name:STEPHENSON, VICKY
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:STEPHENSON
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 1:1700 N VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-8081
Mailing Address - Country:US
Mailing Address - Phone:989-325-0744
Mailing Address - Fax:989-269-6814
Practice Address - Street 1:1700 N VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-8081
Practice Address - Country:US
Practice Address - Phone:989-325-0744
Practice Address - Fax:989-269-6814
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802062911104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker