Healthcare Provider Details

I. General information

NPI: 1952210312
Provider Name (Legal Business Name): STEPHANIE GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 SWAN LAKE DR
ROMULUS MI
48174-6317
US

IV. Provider business mailing address

9315 TELEGRAPH RD
REDFORD MI
48239-1260
US

V. Phone/Fax

Practice location:
  • Phone: 313-590-0384
  • Fax: 734-939-0167
Mailing address:
  • Phone: 313-450-4500
  • Fax: 313-450-4512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: