Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP2500X | Professional Counselor | 6401011218 | MI |
Y | 103TC1900X | Counseling Psychologist | 6301014114 | MI |
NPI | 1003173063 |
---|---|
Provider Name | Stephanie Berg Wright |
First Address | Southfield, MI 48033-3849 |
Second Address | Southfield, MI 48076-1594 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2012 |
Last Update Date | 22/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6301014114 | STATE LICENSE NUMBER (01) | MI |
6401011218 | STATE LICENSE (01) | MI |