Provider Demographics
NPI:1801613328
Name:BLAKEMORE, STEPHANIE MICHELLE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:BLAKEMORE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:SKYE
Other - Middle Name:
Other - Last Name:BLAKEMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2065 CAMBRIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-5235
Mailing Address - Country:US
Mailing Address - Phone:616-916-0251
Mailing Address - Fax:
Practice Address - Street 1:1115 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-456-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511180661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical