Provider Demographics
NPI:1265500615
Name:DR TEDD STEPHENS EDD
Entity Type:Organization
Organization Name:DR TEDD STEPHENS EDD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:DR
Authorized Official - First Name:TEDD
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:423-928-1379
Mailing Address - Street 1:2112 N ROAN ST
Mailing Address - Street 2:6TH FL
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601
Mailing Address - Country:US
Mailing Address - Phone:423-928-1379
Mailing Address - Fax:
Practice Address - Street 1:2112 N ROAN ST
Practice Address - Street 2:6TH FL
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-928-1379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3688713Medicaid
TN3688713Medicaid