Provider Demographics
NPI:1598956369
Name:DETTLOFF-JONES, STACEY MARIE (MA LPC LLP)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MARIE
Last Name:DETTLOFF-JONES
Suffix:
Gender:F
Credentials:MA LPC LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11594 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-2621
Mailing Address - Country:US
Mailing Address - Phone:586-215-0805
Mailing Address - Fax:
Practice Address - Street 1:1410 E 14 MILE RD
Practice Address - Street 2:SUITE 900
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1541
Practice Address - Country:US
Practice Address - Phone:248-524-8801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008747101YP2500X
MI6301013080103T00000X
MI6802072238104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker