Healthcare Provider Details

I. General information

NPI: 1831399914
Provider Name (Legal Business Name): STACEY LYNN MARQUEE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 MONROE CTR NW MCKAY TOWER SUITE 606
GRAND RAPIDS MI
49503-2833
US

IV. Provider business mailing address

146 MONROE CTR NW MCKAY TOWER SUITE 606
GRAND RAPIDS MI
49503-2833
US

V. Phone/Fax

Practice location:
  • Phone: 616-242-0099
  • Fax: 616-242-0099
Mailing address:
  • Phone: 616-242-0099
  • Fax: 616-242-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013480
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: