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General NPI Number Information
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NPI Number | 1003692047
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Entity Type | Individual
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Provider Name | STEPHANIE WISNIEWSKI TLLP
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Gender | Female
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Dates
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Enumeration Date | 09/06/2023
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Last Update Date | 09/19/2024
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Provider Practice Location Address
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Address Line | 26545 AMERICAN DR
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City | SOUTHFIELD
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State | MI
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Zip | 48034-6115
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Country | US
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Telephone | 800-395-3223
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Fax |
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Provider Business Mailing Address
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Address Line | 57236 GOODISON APT 2211
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City | NEW HUDSON
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State | MI
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Zip | 48165-7043
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Country | US
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Telephone | 989-798-3617
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6362010015
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License Number State | MI
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