Provider Demographics
NPI:1689927659
Name:WEBER, STEPHANI R
Entity Type:Individual
Prefix:
First Name:STEPHANI
Middle Name:R
Last Name:WEBER
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 1:3781 MOMENTUM PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5337
Mailing Address - Country:US
Mailing Address - Phone:231-935-6080
Mailing Address - Fax:231-935-6081
Practice Address - Street 1:1250 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-7074
Practice Address - Country:US
Practice Address - Phone:989-348-0550
Practice Address - Fax:989-348-0473
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010956511041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty