Healthcare Provider Details

I. General information

NPI: 1336172485
Provider Name (Legal Business Name): STACEY R GEDEON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY L ROGERS PSYD

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9249 W LAKE CITY RD
HOUGHTON LAKE MI
48629-9602
US

IV. Provider business mailing address

9249 W LAKE CITY RD
HOUGHTON LAKE MI
48629-9602
US

V. Phone/Fax

Practice location:
  • Phone: 989-422-5122
  • Fax: 989-422-4378
Mailing address:
  • Phone: 989-422-5122
  • Fax: 989-422-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301010429
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: