Provider Demographics
NPI:1386753366
Name:STONE, NATHAN MARC (MA TLLP)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:MARC
Last Name:STONE
Suffix:
Gender:M
Credentials:MA TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 W BIG BEAVER RD STE 520
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3442
Mailing Address - Country:US
Mailing Address - Phone:248-646-6659
Mailing Address - Fax:248-642-8645
Practice Address - Street 1:2075 W BIG BEAVER RD STE 520
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3442
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:248-642-8645
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001438213E00000X
MI6301016540103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI298726113Medicaid
4858253120OtherBCBS
P80482OtherBCN
P80482OtherBCN
MI298726113Medicaid