Provider Demographics
NPI:1013013010
Name:STEVENS, MICHAEL L (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:STEVENS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N ARTHUR AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3105
Mailing Address - Country:US
Mailing Address - Phone:208-234-4673
Mailing Address - Fax:208-234-4677
Practice Address - Street 1:109 N ARTHUR AVE STE 203
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3105
Practice Address - Country:US
Practice Address - Phone:208-234-4673
Practice Address - Fax:208-234-4677
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-1279101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807197600Medicaid