Provider Demographics
NPI:1083676522
Name:STEVENS, FRANK (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-339-8109
Practice Address - Street 1:645 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2353
Practice Address - Country:US
Practice Address - Phone:812-339-1691
Practice Address - Fax:812-337-2259
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041469A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200319820Medicaid
Q68697Medicare UPIN
541910IIIIMedicare ID - Type Unspecified