Provider Demographics
NPI:1205025384
Name:MARTIN, STEPHANIE A (MLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9702
Mailing Address - Country:US
Mailing Address - Phone:517-833-8100
Mailing Address - Fax:517-676-5207
Practice Address - Street 1:2702 FLUSHING RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4534
Practice Address - Country:US
Practice Address - Phone:810-424-5998
Practice Address - Fax:810-424-6347
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010125781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty