Provider Demographics
NPI:1093995219
Name:MAILLOUX, STEPHEN L (PH D)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:L
Last Name:MAILLOUX
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 EAST DIMOND BLVD SUITE 3-625
Mailing Address - Street 2:800 EAST DIMOND BLVD SUITE 3-625
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-2025
Mailing Address - Country:US
Mailing Address - Phone:907-306-6525
Mailing Address - Fax:
Practice Address - Street 1:800 EAST DIMOND BLVD SUITE 3-625
Practice Address - Street 2:800 EAST DIMOND BLVD SUITE 3-625
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-2025
Practice Address - Country:US
Practice Address - Phone:907-306-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK539174400000X
AKPSYP539261QM2500X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No174400000XOther Service ProvidersSpecialist
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty