Provider Demographics
NPI:1235158635
Name:SIMON, STEPHEN EARL (MSW)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:EARL
Last Name:SIMON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29260 FRANKLIN RD
Mailing Address - Street 2:STE 115
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1144
Mailing Address - Country:US
Mailing Address - Phone:248-352-7304
Mailing Address - Fax:248-282-0608
Practice Address - Street 1:851 WOODLEA ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-2928
Practice Address - Country:US
Practice Address - Phone:248-825-7218
Practice Address - Fax:248-282-0608
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010050081041C0700X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP12140012Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER