Provider Demographics
NPI:1225821879
Name:STEVENSON, LYDIA ANN (LLC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 60TH ST SE STE B
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7065
Mailing Address - Country:US
Mailing Address - Phone:616-320-2273
Mailing Address - Fax:
Practice Address - Street 1:1401 60TH ST SE STE B
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7065
Practice Address - Country:US
Practice Address - Phone:616-320-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024346101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health