Provider Demographics
NPI:1114967361
Name:HIBBARD, STEPHEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:HIBBARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 W ANN ARBOR TRL
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6262
Mailing Address - Country:US
Mailing Address - Phone:734-673-5850
Mailing Address - Fax:734-414-1586
Practice Address - Street 1:496 W ANN ARBOR TRL
Practice Address - Street 2:SUITE 108
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6262
Practice Address - Country:US
Practice Address - Phone:734-673-5850
Practice Address - Fax:734-414-1586
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010M370103TA0400X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION34680Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER