Provider Demographics
NPI:1750106795
Name:NA, STEPHEN DAVID
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DAVID
Last Name:NA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 136TH AVE STE 416
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2905
Mailing Address - Country:US
Mailing Address - Phone:616-952-9957
Mailing Address - Fax:
Practice Address - Street 1:400 136TH AVE STE 416
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2905
Practice Address - Country:US
Practice Address - Phone:616-952-9957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical