Provider Demographics
NPI:1003692047
Name:WISNIEWSKI, STEPHANIE (TLLP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57236 GOODISON APT 2211
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-7043
Mailing Address - Country:US
Mailing Address - Phone:989-798-3617
Mailing Address - Fax:
Practice Address - Street 1:26545 AMERICAN DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-6115
Practice Address - Country:US
Practice Address - Phone:800-395-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010015103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical