Healthcare Provider Details

I. General information

NPI: 1508760661
Provider Name (Legal Business Name): DARRYL R STANBROUGH, JR MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17320 W 12 MILE RD STE 101
SOUTHFIELD MI
48076-2102
US

IV. Provider business mailing address

17320 W 12 MILE RD STE 101
SOUTHFIELD MI
48076-2102
US

V. Phone/Fax

Practice location:
  • Phone: 248-557-3606
  • Fax: 248-557-4697
Mailing address:
  • Phone: 248-557-3606
  • Fax: 248-557-4697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number261QM0801X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: