Provider Demographics
NPI:1073765178
Name:STEPHENS, ROGER WARREN
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WARREN
Last Name:STEPHENS
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 1:4625 E STOP 11 RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9101
Mailing Address - Country:US
Mailing Address - Phone:317-884-3383
Mailing Address - Fax:
Practice Address - Street 1:4625 E STOP 11 RD
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9101
Practice Address - Country:US
Practice Address - Phone:317-884-3383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31000318A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist