Provider Demographics
NPI:1043221484
Name:STEVENS, MARILYN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:363 S MAIN ST
Practice Address - Street 2:SUITE 220
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523-1417
Practice Address - Country:US
Practice Address - Phone:217-638-5545
Practice Address - Fax:217-424-1633
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
149001214101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209702Medicare ID - Type Unspecified