Provider Demographics
NPI:1194058735
Name:CAPTAIN, STEPHANIE R
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:CAPTAIN
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 1:29691 6 MILE RD STE 100D
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-8606
Mailing Address - Country:US
Mailing Address - Phone:866-727-8274
Mailing Address - Fax:
Practice Address - Street 1:29691 6 MILE RD STE 100D
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-8606
Practice Address - Country:US
Practice Address - Phone:866-727-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007205101YP2500X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional