Provider Demographics
NPI:1184631525
Name:STEVENSON, ROBERT LOUIS BANNATYNE (CLINICAL AUDIOLOGIST)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOUIS BANNATYNE
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:CLINICAL AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5203
Mailing Address - Country:US
Mailing Address - Phone:435-753-4133
Mailing Address - Fax:435-753-7364
Practice Address - Street 1:293 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5203
Practice Address - Country:US
Practice Address - Phone:435-753-4133
Practice Address - Fax:435-753-7364
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT376947-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist