Basic Information
| Provider Information | |||||||||
| NPI: | 1083676522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 S ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391691 | ||||||||
| FaxNumber: | 8123398109 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 S ROGERS ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123391691 | ||||||||
| FaxNumber: | 8123372259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 04/29/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 20041469A | IN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 200319820 | 05 | IN | MEDICAID |