Basic Information
| Provider Information | |||||||||
| NPI: | 1245355361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LUCAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMLP, LCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671142037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162831950 | ||||||||
| FaxNumber: | 3162839540 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 LARIAT WAY | ||||||||
| Address2: | |||||||||
| City: | DODGE CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678017328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202250276 | ||||||||
| FaxNumber: | 6202250276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 0141 | KS | X | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 0136 | KS | X | Behavioral Health & Social Service Providers | Psychologist | 103TP2701X | 0141 | KS | X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TP2701X | 0136 | KS | X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No ID Information.