Provider Demographics
NPI:1447915863
Name:STEFANI, BRADY GEE
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:GEE
Last Name:STEFANI
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 1:411 PINGREE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1818
Mailing Address - Country:US
Mailing Address - Phone:248-225-5460
Mailing Address - Fax:
Practice Address - Street 1:411 PINGREE BLVD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1818
Practice Address - Country:US
Practice Address - Phone:248-225-5460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009406103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty