Healthcare Provider Details

I. General information

NPI: 1679222574
Provider Name (Legal Business Name): STEPHANIE BROWN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

V. Phone/Fax

Practice location:
  • Phone: 616-825-5469
  • Fax:
Mailing address:
  • Phone: 161-626-2346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801107221
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851107221
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115043
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: