Provider Demographics
NPI:1043482854
Name:TISSUE, STACEY LYNN (LLBSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:TISSUE
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4090 WELLMAN LINE RD
Mailing Address - Street 2:
Mailing Address - City:JEDDO
Mailing Address - State:MI
Mailing Address - Zip Code:48032-8105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2875 HENRY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2526
Practice Address - Country:US
Practice Address - Phone:810-987-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086138171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator