Provider Demographics
NPI:1629601729
Name:BEATON, STEPHANIE (LLMSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BEATON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3332 23RD ST
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-6015
Mailing Address - Country:US
Mailing Address - Phone:734-747-1105
Mailing Address - Fax:
Practice Address - Street 1:3011 W GRAND BLVD STE 406
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3011
Practice Address - Country:US
Practice Address - Phone:734-258-7086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011063121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical