Provider Demographics
NPI:1164681730
Name:STEVENS, MARK WAYNE (LPC, CSAC II)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WAYNE
Last Name:STEVENS
Suffix:
Gender:M
Credentials:LPC, CSAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PEZOLD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7930
Mailing Address - Country:US
Mailing Address - Phone:314-452-6402
Mailing Address - Fax:
Practice Address - Street 1:12166 OLD BIG BEND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6844
Practice Address - Country:US
Practice Address - Phone:314-452-6402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-08
Last Update Date:2008-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0794101YA0400X
MO2006012732106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)