Healthcare Provider Details

I. General information

NPI: 1629624390
Provider Name (Legal Business Name): STEPHANIE ROSE FISHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2019
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7616 CLYDE PARK AVE SW STE G
BYRON CENTER MI
49315-9541
US

IV. Provider business mailing address

1431 ANDREW ST SE
KENTWOOD MI
49508-4813
US

V. Phone/Fax

Practice location:
  • Phone: 616-591-6431
  • Fax:
Mailing address:
  • Phone: 616-325-8997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401017534
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: