Healthcare Provider Details

I. General information

NPI: 1013139872
Provider Name (Legal Business Name): WADE RANDOLPH STITT M.A.C., L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15146 16TH AVE
MARNE MI
49435-9605
US

IV. Provider business mailing address

15146 16TH AVE
MARNE MI
49435-9605
US

V. Phone/Fax

Practice location:
  • Phone: 844-776-9651
  • Fax:
Mailing address:
  • Phone: 844-776-9651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401009358
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: