Provider Demographics
NPI:1124871512
Name:BUCK-STEWART, BEVERLY JEAN
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JEAN
Last Name:BUCK-STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 LEDYARD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2641
Mailing Address - Country:US
Mailing Address - Phone:313-962-9446
Mailing Address - Fax:313-502-5147
Practice Address - Street 1:445 LEDYARD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2641
Practice Address - Country:US
Practice Address - Phone:313-962-9446
Practice Address - Fax:313-502-5147
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health