Provider Demographics
NPI:1134559982
Name:LITTLE, STEPHANIE ANN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:LITTLE
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 1:30525 PARDO ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-1845
Mailing Address - Country:US
Mailing Address - Phone:734-552-2499
Mailing Address - Fax:313-831-8787
Practice Address - Street 1:10 PETERBORO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2722
Practice Address - Country:US
Practice Address - Phone:313-461-5202
Practice Address - Fax:313-831-8787
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011003451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000197653 01OtherTOTAL HEALTH CARE