MEDICARE: STEPHANIE ROSE FISHER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	6401017534	MI

General Provider Information

NPI Number	:	1629624390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ROSE FISHER

Provider Business Mailing Address
First Line	:	1431 ANDREW ST SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49508-4813
Country	:	US
Telephone Number	:	616-325-8997
Fax Number	:

Provider Business Practice Location Address
First Line	:	7616 CLYDE PARK AVE SW STE G
Second Line	:
City	:	BYRON CENTER
State	:	MI
Zip	:	49315-9541
Country	:	US
Telephone Number	:	616-591-6431
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2019
Last Update Date	:	02/27/2026

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