Provider Demographics
NPI:1275023434
Name:STEGEMAN, NICOLE TAMRA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:TAMRA
Last Name:STEGEMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-7135
Mailing Address - Fax:616-840-9690
Practice Address - Street 1:7125 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-4943
Practice Address - Country:US
Practice Address - Phone:269-492-6575
Practice Address - Fax:269-492-6577
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7101008740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI462053890OtherAUTISM CENTERS OF MICHIGAN