Healthcare Provider Details

I. General information

NPI: 1780862789
Provider Name (Legal Business Name): JASON G STENTOUMIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 E MOUNT HOPE AVE
LANSING MI
48910-1913
US

IV. Provider business mailing address

PO BOX 2257
CHESTERTON IN
46304-0357
US

V. Phone/Fax

Practice location:
  • Phone: 517-999-3935
  • Fax: 517-372-2542
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013410
License Number StateMI

VIII. Authorized Official

Name: JASON G STENTOUMIS
Title or Position: OWNER
Credential: PHD
Phone: 517-999-3935