Healthcare Provider Details

I. General information

NPI: 1114406097
Provider Name (Legal Business Name): STEPHANIE CHOI LPC-MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE BENNETT LPC-MHSP

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 FRONT AVE NW STE 100
GRAND RAPIDS MI
49504-5323
US

IV. Provider business mailing address

678 FRONT AVE NW STE 100
GRAND RAPIDS MI
49504-5323
US

V. Phone/Fax

Practice location:
  • Phone: 616-916-3711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number88420
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6600
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401018624
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: