Provider Demographics
NPI:1073508578
Name:STEPHAN, AMY R (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:STEPHAN
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 1:224 GREAT BRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3904
Mailing Address - Country:US
Mailing Address - Phone:757-819-6121
Mailing Address - Fax:757-819-6149
Practice Address - Street 1:224 GREAT BRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3904
Practice Address - Country:US
Practice Address - Phone:757-819-6121
Practice Address - Fax:757-819-6149
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040032881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA086778OtherSENTARA/OPTIMA
VA321005OtherANTHEM TRIGON
VA276613OtherMAMSI-UNITED HEALTHCARE
VA324100OtherFED HEALTH SERV TRICARE
VA527433OtherVALUE OPTIONS