Provider Demographics
NPI:1851818900
Name:MEDERSKI, MACY NICOLE
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:NICOLE
Last Name:MEDERSKI
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 1:7763 PARTRIDGE HILL DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-8291
Mailing Address - Country:US
Mailing Address - Phone:810-623-7092
Mailing Address - Fax:
Practice Address - Street 1:3887 OKEMOS RD STE A1
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3663
Practice Address - Country:US
Practice Address - Phone:517-992-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician