Basic Information
| Provider Information | |||||||||
| NPI: | 1699808550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROSS | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FISHER | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1555 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488679775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897236791 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1555 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488679775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897236791 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801087073 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0G86087 | 01 | BCBS | OTHER | 01005765 | 01 | HEALTHPLUS OF MICHIGAN | OTHER |