Provider Demographics
NPI:1174631816
Name:STEVENS, MICHAEL JONATHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JONATHAN
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E GROVE STREET
Mailing Address - Street 2:SUITE F
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701
Mailing Address - Country:US
Mailing Address - Phone:309-662-5293
Mailing Address - Fax:309-438-5789
Practice Address - Street 1:901 E GROVE STREET
Practice Address - Street 2:SUITE F
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701
Practice Address - Country:US
Practice Address - Phone:309-662-5293
Practice Address - Fax:309-438-5789
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical