Provider Demographics
NPI:1346873932
Name:NARDUZZI, STACEY R (TLLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:NARDUZZI
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14224 BERWICK ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-4235
Mailing Address - Country:US
Mailing Address - Phone:248-245-0920
Mailing Address - Fax:
Practice Address - Street 1:595 FOREST AVE STE 7A
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1777
Practice Address - Country:US
Practice Address - Phone:734-446-5466
Practice Address - Fax:734-446-2716
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016074103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical