Provider Demographics
NPI:1669065421
Name:RIVERS EDGE PSYCHOLOGICAL SERVICES PC
Entity type:Organization
Organization Name:RIVERS EDGE PSYCHOLOGICAL SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:GILL
Authorized Official - Last Name:SCALCUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-642-8803
Mailing Address - Street 1:717 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2929
Mailing Address - Country:US
Mailing Address - Phone:734-258-3518
Mailing Address - Fax:
Practice Address - Street 1:12240 OELKE RD
Practice Address - Street 2:
Practice Address - City:MAYBEE
Practice Address - State:MI
Practice Address - Zip Code:48159-9779
Practice Address - Country:US
Practice Address - Phone:734-642-8803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-12
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVS0190006Medicaid