Healthcare Provider Details

I. General information

NPI: 1902579683
Provider Name (Legal Business Name): MARY STOTHARD TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W WACKERLY ST STE 11
MIDLAND MI
48640-2769
US

IV. Provider business mailing address

PO BOX 2875
MIDLAND MI
48641-2875
US

V. Phone/Fax

Practice location:
  • Phone: 989-832-2165
  • Fax:
Mailing address:
  • Phone: 989-832-2165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009365
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: