Basic Information
| Provider Information | |||||||||
| NPI: | 1528263787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | ANGEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | CT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 72258 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997072258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074527221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2550 LAWLOR RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997096458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074554725 | ||||||||
| FaxNumber: | 9074554730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CERTIFICATE 3215 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | DA4437 | 05 | AK | MEDICAID |