Provider Demographics
NPI:1366948937
Name:MCGOWAN, STEPHANIE LAVERNE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAVERNE
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1728
Mailing Address - Country:US
Mailing Address - Phone:810-233-4031
Mailing Address - Fax:810-237-4141
Practice Address - Street 1:129 E. THIRD STREET
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502
Practice Address - Country:US
Practice Address - Phone:810-233-4031
Practice Address - Fax:810-237-4141
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008208101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health