Basic Information
| Provider Information | |||||||||
| NPI: | 1366109316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5405 SHAUFF PL | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374092320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9718015230 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 S PIERCE AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504012711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414945000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2021 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SC61222177 | WA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.