Provider Demographics
NPI:1639594799
Name:BAZYDLO, STEPHANIE (RD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BAZYDLO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50505 SCHOENHERR RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:SUITE 240
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:313-207-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002369133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered