Healthcare Provider Details

I. General information

NPI: 1124489786
Provider Name (Legal Business Name): DR. MICHELLE STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 03/09/2024
Certification Date: 03/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 STICKLEY RD
COLUMBIA SC
29229-6889
US

IV. Provider business mailing address

631 STICKLEY RD
COLUMBIA SC
29229-6889
US

V. Phone/Fax

Practice location:
  • Phone: 301-875-6567
  • Fax:
Mailing address:
  • Phone: 130-187-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR02162
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberD14115-27
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13459
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberRO2162
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: