=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376017137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACY K DOCTOROFF LLPC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2019
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29260 FRANKLIN RD STE 111
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-259-5642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26413 HUNTINGTON RD
-----------------------------------------------------
City | HUNTINGTON WOODS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48070-1263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-259-5642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/COUNSELOR
-----------------------------------------------------
Name | STACY K DOCTOROFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-259-5642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------