Provider Demographics
NPI:1730240359
Name:SCHAEFER SPACE, JULIE ANNA (MS, MLLP)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANNA
Last Name:SCHAEFER SPACE
Suffix:
Gender:F
Credentials:MS, MLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 339
Mailing Address - Street 2:402 THORNTON STREET
Mailing Address - City:MIDDLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49333-4209
Mailing Address - Country:US
Mailing Address - Phone:269-795-2243
Mailing Address - Fax:269-795-5315
Practice Address - Street 1:402 THORNTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:49333-9706
Practice Address - Country:US
Practice Address - Phone:269-795-2243
Practice Address - Fax:269-795-5315
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007868103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
157890OtherVALUE OPTIONS
214526000OtherMAGELLAN