Provider Demographics
NPI:1063637148
Name:STEVENS, DENNIS LEE (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:LEE
Last Name:STEVENS
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-2623
Mailing Address - Country:US
Mailing Address - Phone:217-234-6426
Mailing Address - Fax:217-234-9853
Practice Address - Street 1:321 LAKE LAND BLVD
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-3905
Practice Address - Country:US
Practice Address - Phone:217-234-6426
Practice Address - Fax:217-234-9853
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0334237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL332B00000XMedicaid