Provider Demographics
NPI:1164797569
Name:BEAN, STACY (MSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BEAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12220 E 13 MILE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5000
Mailing Address - Country:US
Mailing Address - Phone:586-573-1810
Mailing Address - Fax:586-573-2121
Practice Address - Street 1:12220 E 13 MILE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-5000
Practice Address - Country:US
Practice Address - Phone:586-573-1810
Practice Address - Fax:586-573-2121
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010872741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical