Basic Information
| Provider Information | |||||||||
| NPI: | 1669811592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | BSW/LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104965410 | ||||||||
| FaxNumber: | 8102573795 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104965410 | ||||||||
| FaxNumber: | 8102573795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2013 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802072068 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 6802072068 | 01 | MI | BACHELOR'S SOCIAL WORKER LICENSE | OTHER |