Basic Information
| Provider Information | |||||||||
| NPI: | 1144967449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BM, MT-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2712 WESTBROOK ST APT E19 | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490066924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176078041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3283 122ND AVE | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696736617 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2022 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.