Provider Demographics
NPI:1093860561
Name:MACK B. STEPHENSON, PH.D., CHTD
Entity Type:Organization
Organization Name:MACK B. STEPHENSON, PH.D., CHTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MACK
Authorized Official - Middle Name:B
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-288-0692
Mailing Address - Street 1:78 SW 5TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2923
Mailing Address - Country:US
Mailing Address - Phone:208-288-0692
Mailing Address - Fax:208-288-0467
Practice Address - Street 1:78 SW 5TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2923
Practice Address - Country:US
Practice Address - Phone:208-288-0692
Practice Address - Fax:208-288-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202056103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty