Healthcare Provider Details

I. General information

NPI: 1902211121
Provider Name (Legal Business Name): STEPHANIE HASTY MIKULSKI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

PO BOX 670884
DETROIT MI
48267-0884
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5101021146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: