Provider Demographics
NPI:1669130910
Name:WICKER, STEPHANIE DANIELLE (LMSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLE
Last Name:WICKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:DANIELLE
Other - Last Name:DOSSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:13120 OLD HICKORY TRL
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1921 E MILLER RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-5348
Practice Address - Country:US
Practice Address - Phone:517-319-0673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011054201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical