Provider Demographics
NPI:1790436889
Name:STEPHENS, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:STEPHENS
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:PO BOX 51723
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48151-5723
Mailing Address - Country:US
Mailing Address - Phone:586-634-1189
Mailing Address - Fax:
Practice Address - Street 1:13101 ECKLES RD STE 102
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4245
Practice Address - Country:US
Practice Address - Phone:313-288-9736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703055239164W00000X
2279H0200X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No2279H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredHome Health