Provider Demographics
NPI:1891984225
Name:MOHAMMED, STACIE M (BA, LBSW, QMRP)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:M
Last Name:MOHAMMED
Suffix:
Gender:F
Credentials:BA, LBSW, QMRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6705 LARK ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-2317
Mailing Address - Country:US
Mailing Address - Phone:313-925-9428
Mailing Address - Fax:
Practice Address - Street 1:30445 NORTHWESTERN HWY STE 210
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3163
Practice Address - Country:US
Practice Address - Phone:248-855-8422
Practice Address - Fax:248-855-8412
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802074867104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker