Healthcare Provider Details

I. General information

NPI: 1801613328
Provider Name (Legal Business Name): STEPHANIE MICHELLE BLAKEMORE
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: SKYE BLAKEMORE

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

2065 CAMBRIDGE DR SE
GRAND RAPIDS MI
49506-5235
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax:
Mailing address:
  • Phone: 616-916-0251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851118066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: