Provider Demographics
NPI:1699824904
Name:STANCZAK, STANLEY (MSW)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:STANCZAK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25869 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4997
Mailing Address - Country:US
Mailing Address - Phone:586-773-6020
Mailing Address - Fax:586-773-6093
Practice Address - Street 1:25869 KELLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4997
Practice Address - Country:US
Practice Address - Phone:586-773-6020
Practice Address - Fax:586-773-6093
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010012591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION99040001Medicare ID - Type Unspecified