Provider Demographics
NPI:1366284960
Name:STEVENS, GLENN AMIN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:AMIN
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4039 KENDALL ST # 2
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2654
Mailing Address - Country:US
Mailing Address - Phone:313-399-1816
Mailing Address - Fax:
Practice Address - Street 1:9684 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-1048
Practice Address - Country:US
Practice Address - Phone:313-459-4146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide