Healthcare Provider Details

I. General information

NPI: 1174105811
Provider Name (Legal Business Name): HEIDI STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43155 MAIN ST STE 2300G
NOVI MI
48375-1889
US

IV. Provider business mailing address

21528 JACKSONVILLE ST
FARMINGTON HILLS MI
48336-5728
US

V. Phone/Fax

Practice location:
  • Phone: 734-323-4897
  • Fax:
Mailing address:
  • Phone: 607-280-9868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number6352000556
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: