Provider Demographics
NPI:1053046326
Name:STEVENSON, KEANNA
Entity Type:Individual
Prefix:
First Name:KEANNA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 SWEET PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSTOCK
Mailing Address - State:SC
Mailing Address - Zip Code:29014-8631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5910 SWEET PROSPECT RD
Practice Address - Street 2:
Practice Address - City:BLACKSTOCK
Practice Address - State:SC
Practice Address - Zip Code:29014-8631
Practice Address - Country:US
Practice Address - Phone:803-899-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant