Provider Demographics
NPI:1336172485
Name:GEDEON, STACEY R (PSYD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:GEDEON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:9249 W LAKE CITY RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9602
Mailing Address - Country:US
Mailing Address - Phone:989-422-5122
Mailing Address - Fax:989-422-4378
Practice Address - Street 1:9249 W LAKE CITY RD
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9602
Practice Address - Country:US
Practice Address - Phone:989-422-5122
Practice Address - Fax:989-422-4378
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG27604070OtherMEDICARE PTAN
MIG27604070OtherMEDICARE PTAN