Provider Demographics
NPI:1730959511
Name:FOSTER, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:FOSTER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W GRAND BLVD STE 370
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3008
Mailing Address - Country:US
Mailing Address - Phone:313-468-4371
Mailing Address - Fax:313-731-1991
Practice Address - Street 1:3031 W GRAND BLVD STE 370
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3008
Practice Address - Country:US
Practice Address - Phone:313-468-4371
Practice Address - Fax:313-731-1991
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)