Healthcare Provider Details

I. General information

NPI: 1932465325
Provider Name (Legal Business Name): STACEY MARIE MEJIA LMSW, CAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43450 W 10 MILE RD
NOVI MI
48375-3172
US

IV. Provider business mailing address

43450 W 10 MILE RD
NOVI MI
48375-3172
US

V. Phone/Fax

Practice location:
  • Phone: 248-344-7420
  • Fax:
Mailing address:
  • Phone: 248-344-7420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801066758
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: