Provider Demographics
NPI:1639585060
Name:MOUZON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MOUZON
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 1:25763 VALLEY CREEK DR
Mailing Address - Street 2:APT 602
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-4011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41521 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1803
Practice Address - Country:US
Practice Address - Phone:248-299-0030
Practice Address - Fax:248-438-1566
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149813103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst