Healthcare Provider Details

I. General information

NPI: 1598877714
Provider Name (Legal Business Name): KEVIN B STACHOWIAK LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10751 S SAGINAW ST STE L
GRAND BLANC MI
48439-8169
US

IV. Provider business mailing address

10751 S SAGINAW ST STE L
GRAND BLANC MI
48439-8169
US

V. Phone/Fax

Practice location:
  • Phone: 866-227-2708
  • Fax:
Mailing address:
  • Phone: 810-691-3916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095065
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: