Basic Information
| Provider Information | |||||||||
| NPI: | 1326568601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANNATTER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEEKS | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9844 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | IRA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480232813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107167600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9844 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | IRA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480232813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867167600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401016146 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.