Provider Demographics
NPI:1790164465
Name:STEVENS, AZIBO KHUFU
Entity Type:Individual
Prefix:MR
First Name:AZIBO
Middle Name:KHUFU
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35425 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-9800
Mailing Address - Country:US
Mailing Address - Phone:734-467-7600
Mailing Address - Fax:734-467-7646
Practice Address - Street 1:22255 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3729
Practice Address - Country:US
Practice Address - Phone:248-849-3301
Practice Address - Fax:248-849-5349
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096258171M00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator