Provider Demographics
NPI:1316721400
Name:EBELT, STACIA JEAN
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:JEAN
Last Name:EBELT
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 1:12142 LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-8119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20300 SUPERIOR RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6331
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010045103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical