Provider Demographics
NPI:1003282419
Name:STEPHENS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-1514
Mailing Address - Country:US
Mailing Address - Phone:845-235-6618
Mailing Address - Fax:
Practice Address - Street 1:16250 NORTHLAND DR STE 223
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5205
Practice Address - Country:US
Practice Address - Phone:845-235-6618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25004465171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist