Basic Information
| Provider Information | |||||||||
| NPI: | 1740395920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | HAD-F | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 N MARIETTA PKWY | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300608023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705908662 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 145 N MARIETTA PKWY | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300608023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705908662 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 2124 | AL | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237700000X | HADS000963 | GA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 035185274 | 01 | GA | DL | OTHER |