Provider Demographics
NPI:1235283003
Name:HYSLOP, STANFORD KENT (LMSW)
Entity Type:Individual
Prefix:MR
First Name:STANFORD
Middle Name:KENT
Last Name:HYSLOP
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:801 HAZEN STREET SUITE C
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0249
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-3474
Practice Address - Street 1:801 HAZEN STREET
Practice Address - Street 2:SUITE C
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-0249
Practice Address - Country:US
Practice Address - Phone:269-657-5574
Practice Address - Fax:269-657-3474
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801063268104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIHO6346030Medicare PIN