Provider Demographics
NPI:1477784932
Name:STEPHAN, PATRICIA JEAN
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEAN
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-1976
Mailing Address - Country:US
Mailing Address - Phone:231-726-4735
Mailing Address - Fax:231-722-0789
Practice Address - Street 1:1195 E WILCOX AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8673
Practice Address - Country:US
Practice Address - Phone:231-689-6701
Practice Address - Fax:231-689-6702
Is Sole Proprietor?:No
Enumeration Date:2009-08-01
Last Update Date:2009-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010647621041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health