Basic Information
| Provider Information | |||||||||
| NPI: | 1922031640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 G ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958141802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168265905 | ||||||||
| FaxNumber: | 9164401514 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 A ST BLDG A | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958140631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164401500 | ||||||||
| FaxNumber: | 9164401514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 104100000X | LCS 20787 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.