Basic Information
| Provider Information | |||||||||
| NPI: | 1598956369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETTLOFF-JONES | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MA LPC LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11594 DIAMOND DR | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862150805 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1410 E 14 MILE RD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480711541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485248801 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401008747 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | 6301013080 | MI | N | Behavioral Health & Social Service Providers | Psychologist | 104100000X | 6802072238 | MI | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.