Provider Demographics
NPI:1790095594
Name:STODDARD, DENISE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:ANN
Last Name:STODDARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W. FERRY STREET
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1664
Mailing Address - Country:US
Mailing Address - Phone:269-815-5331
Mailing Address - Fax:269-815-5061
Practice Address - Street 1:300 W FERRY ST
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1109
Practice Address - Country:US
Practice Address - Phone:269-815-5331
Practice Address - Fax:269-815-5061
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013677103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling