Provider Demographics
NPI:1255095550
Name:STEVENS, DAVID CARL (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CARL
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:MR
Other - First Name:DAVE
Other - Middle Name:CARL
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2021-10-24
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201041299RN163W00000X
WARN61146170163W00000X
WAAP61337481363L00000X
OR202111950NP-PP363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2205261Medicaid
OR500800742Medicaid