Provider Demographics
NPI:1023569472
Name:HANCOCK, STEPHAN K
Entity Type:Individual
Prefix:MR
First Name:STEPHAN
Middle Name:K
Last Name:HANCOCK
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:PO BOX 5664
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-5664
Mailing Address - Country:US
Mailing Address - Phone:575-590-7883
Mailing Address - Fax:
Practice Address - Street 1:72 GAIL HARRIS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-8116
Practice Address - Country:US
Practice Address - Phone:575-347-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0159701101YA0400X
NMM-087661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28858735Medicaid
323026Medicare PIN