Provider Demographics
NPI:1629624390
Name:WEST, STEPHANIE ROSE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROSE
Last Name:WEST
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 1:2767 20 MILE RD
Mailing Address - Street 2:
Mailing Address - City:KENT CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49330-9791
Mailing Address - Country:US
Mailing Address - Phone:616-325-8997
Mailing Address - Fax:
Practice Address - Street 1:2305 E PARIS AVE SE STE 203
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2426
Practice Address - Country:US
Practice Address - Phone:616-481-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health